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INSIDE HEALTH

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ÌýProgramme 10.

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TX:Ìý 10.03.15Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up today:Ìý Sex education – it’s come on a bit since the days of the birds and the bees but should schools be doing more?

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Cosmetic surgery – we examine the latest report from the UK which, contrary to what you might expect, indicates that fewer people are going under the knife to improve their appearance.

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Clip

In some areas reductions of up to 25 or 30% would seem that there’s been a dramatic change in the way patients are behaving.

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Porter

And we go to Las Vegas and New York to find out what is going on there. Because in this field where the Americans lead, we so often follow.

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And gallstones – we answer a listener’s question about when they need removing and when they don’t.

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But first, the big news in public health this week is the parliamentary vote on the introduction of standardised cigarette packets.Ìý A move the tobacco industry has resisted fiercely. But what sort of impact might standardised packaging have on the nation’s smoking habits?

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To debate the issue Martin Mckee, who’s Professor of Public Health at the London School of Hygiene and Tropical Medicine and Linda Bauld, Professor of Health policy at the University of Stirling.

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Bauld

The reason it’s a good idea is because of what’s happened in the UK and many other countries is that the tobacco industry’s ability to promote and advertise its products has been gradually removed, through legislation.Ìý So we saw bans for example on television advertising, billboards etc.Ìý And so what happened was as that was removed the industry placed its considerable marketing and promotion budget into the pack and we saw a lot of innovation around tobacco packaging, particularly in recent years.Ìý So the pack became a marketing tool and it tried to communicate to young people and to current smokers.Ìý So when we looked at the evidence we found it was really substantial in relation to if you remove that marketing and branding it reduces the appeal of the products, it reduces the confusion that the packaging can convey to smokers about what’s inside and importantly it also makes those health warnings, that are on the pack, more visible and more prominent.

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Porter

Now when you were talking about evidence I mean pre-Australia, which is the first country in the world to introduce standardised packaging, that evidence was based on what?

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Bauld

So when we looked at it it was across a number of countries, their experimental studies where people had been asked to look at different types of packs and give their response, studies where people have been asked to use plain packs in real life and see how that changed their attitudes or their smoking behaviour.Ìý So it’s those kinds of studies, you’re right they’re not randomised control trials but they’re…

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Porter

But the idea is you can extrapolate out the findings.

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Bauld

That’s right.

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Porter

Martin, we’re obviously in a position now where Australia have been the first country in the world to introduce standardised packaging, is it too early to a result from that?

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Mckee

No it’s not and in fact we now have a wealth of evidence from Australia which completely confounds what the tobacco industry had claimed. ÌýSo we have seen now smoking going to its lowest rate ever, going to 12.8%, in Australia.Ìý We have seen that there has not been an increase in illegal trade, which was what the industry proposed that there would be.Ìý We’re now seeing that there is a significant reduction in the number of young people who are taking up smoking, which is what we would expect.Ìý This is directed at people initiating smoking.Ìý Also we are seeing some impact of people who are established smokers as well, that was not expected to happen so much.Ìý So we’re seeing an additional benefit above and beyond what was predicted.

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Bauld

That’s an important point, the way we’ve described in the UK it’s about prevention largely but Martin’s absolutely right – the studies coming out of Australia now show, for example, that people are ringing the quit line more often than they were before – the adults.Ìý Adults feel more uncomfortable about using the pack and taking it out in public, that’s some of the studies that have been done.Ìý And also very importantly from my perspective who does research on smoking cessation people are more often thinking about quitting and they’re trying to stop more frequently since this policy’s been introduced.Ìý Now this is new evidence but it’s important and it’s interesting, we need to follow it but it’s promising.

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Mckee

And following on from that we’re also finding now that a majority of Australian smokers support the introduction of standardised packaging, this is very similar to what happened with the ban on smoking in public places here where once it was introduced we found that even smokers were supportive of it.

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Porter

Can you explain how standardised packaging helps?

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Bauld

Okay, so if you imagine that the pack communicates with someone, the way that a packaging of a particular food product or anything else that people might like to consume communicates with us, gives us information about the product, what the cigarette pack has done increasingly in recent years is it’s tried to convey a particular image to the smoker, it might be for men or women, you’ll see the very attractive brands of cigarettes for women that we have now, the slims are very feminine.Ìý It also tries to convey that products have different types of strength, so for example if you ask smokers in studies, in experimental studies, they see packs with stronger colours potentially as stronger cigarettes and those with lighter colours as less harmful.Ìý Now that’s nonsense because all cigarettes are equally harmful but the industry’s very effectively used packaging as a communication tool.Ìý And then the other thing the packaging does, particularly with those slim packs I mentioned, is the visual health warnings we’ve required since 2008, they’re less noticeable when you have all the other very attractive branding and packaging on there, so it takes away from that measure.Ìý So those are some of the things that packaging does.

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Porter

Martin, it is noticeable, if you look at a tobacco counter, and many of them are closed off in the bigger retailers now, but if you look at the tobacco counter there’s lots of silvers and golds and blues and greens and whites – it’s changed very much over the last 20 years.Ìý And presumably they’re doing that because they know it helps them sell cigarettes?

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Mckee

Well they know that it helps them sell cigarettes because they have been doing exactly the same research that people like Linda have been doing to understand what attracts people.Ìý Remember that the tobacco industry is a major investor in brain imaging research.

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Porter

Let’s unpick some of the tobacco industry’s defence.Ìý First of all there’s the use of the term plain packaging versus standardised packaging – is there a difference?

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Mckee

Yes there absolutely is.Ìý There’s a myth going around that these are plain packs, these are going to be plain white packs, they’re not, these are standardised packaging.Ìý They’re going to be probably a green colour with large health warnings on them, with security markings and so on.Ìý But the industry is doing all sorts of things to show pictures of white iPhones, for example, and saying well they’re saying that a plain package won’t sell but of course these do, that’s not what is being produced, these packs are anything but plain – they have large visual warnings on them.

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Porter

So what do they look like in Australia, can you describe a….?

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Mckee

Yeah they have a green background, they have a picture warning covering a large proportion of the surface of the packs, the name of the brand is there but it is there in small writing.

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Porter

And all the packs look the same effectively?

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Mckee

All the packs look the same.Ìý So it’s been possible to take away all the imagery that they have been using to attract young people.

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Porter

The other defence that the industry put up is it’ll just make it easier for counterfeit, smugglers if you like.

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Mckee

That’s absolutely not true.Ìý They will have powerful security markings on them and what we’ve seen in Australia is that – and surveys the number of people who are smoking the cigarettes that have been smuggled in or brought in by duty free typically, have actually fallen and in attempts at mystery shopping that have gone out to cigarette outlets to look at what’s available, to see what they can buy, again the number of smuggled cigarettes they’ve been able to find has been miniscule.Ìý So we’ve got to recognise there’s a huge amount of mythology here.

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Porter

If this is passed when do you think we’ll see our first standardised packs on the shelves?

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Bauld

It’s not going to happen overnight, this is a change for the industry, they need to be given time to implement that change.Ìý The regulations will have to be worked out in some detail, they’ve been tabled but not worked through.Ìý So I would imagine probably about another year or so really before we see a standardised pack, that would be my prediction.

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Porter

Looking forward, assuming the vote goes the way that you’d like it to go, what sort of impact do you predict it’s going to have here in the UK?

Bauld

I think it’s important for people to recognise that this is part of a package of measures.Ìý You know adult smokers that I work with in our trials and studies often say to me you know I didn’t start smoking because of the pack, it’s not going to make any difference to me and that’s their view and that’s perfectly acceptable.Ìý But the point is that when you add the standardised packaging to smoke-free public places, to the existing ban on advertising, to stop smoking services etc., what you have is a lot of things that are prompting people to think about giving up.Ìý And also speaking to young people about the fact that it’s a damaging health behaviour that they shouldn’t engage in.Ìý One thing I always find in my studies is that most of the smokers I work with try many times to stop, there are different triggers to stopping and it can be anything from seeing a TV advert, talking to somebody about smoking, whatever, and it may well be that a standardised pack will just provide an extra trigger, being able to see the warning, think about it a bit more, that will contribute to that.Ìý So I think it’s about another bit of the jigsaw.

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Mckee

I think that’s a very important message because people often say well one particular measure in isolation will not make a huge difference and of course that is true.Ìý We’ve done work which is under review at the minute which is looking worldwide at about 20 countries and showing that it really is the cumulative effect and those countries that have implemented the whole range of measures which are set out in the WHO framework convention into tobacco control are the ones which really get the good results.Ìý You go along for a while and when you get everything in place then you really hit the jackpot.

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Porter

Why wouldn’t the vote go through?

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Mckee

Well I think it will go through actually, I think the evidence is so overwhelming.Ìý But of course there are a number of members of parliament who have been lavishly entertained by the tobacco industry.

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Porter

It’s a powerful lobbying group.

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Mckee

And if we look at those MPs who have voted against measures on tobacco there’s a very clear correlation.Ìý One of the things that is changing, however, is that a number of MPs, particularly the Northern Irish ones that have typically been opposed to any measures to limit smoking, have now lost the link with the tobacco industry in their constituencies – companies like Gallagher is pulling out of Northern Ireland – because the industry is now moving its production to very low cost countries.Ìý So I think that might be one change that might make a difference.

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Bauld

I think the other thing to emphasise is that the devolved nations really are very supportive of this policy and this is a vote in Westminster but the Scottish government has said they’ll go ahead.Ìý So I think that kind of pressure is useful.Ìý Martin’s absolutely right though there will be people who vote against it for lots of different reasons.Ìý But one of the things we’ve seen consistently with tobacco measures is there’s a lot of cross party support and that’s what we see in this instance as well.

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Porter

Linda Bauld and Martin Mckee.

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Any change in the law will only apply to England and Wales but, as we have just heard, Scotland is keen to introduce similar legislation.

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Now, the thorny issue of when and how to tell children about sex. Schools throughout England are to be offered new guidance to help them with sex education in PHSE classes for key stage three and four pupils. But, controversially, the classes are still not going to be made a statutory part of the curriculum despite a recent recommendation from the Education Select Committee that they should be.Ìý

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Inside Health’s Margaret McCartney has been looking at the evidence. Margaret what does the latest research suggest about the role of schools?

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McCartney

There’s two really good papers this week in the BMJ open journal, which are free access so anyone can read them, which really I think go some way to try and answer some of these kind of questions.Ìý The first paper asked 4,000 men and women aged between 16 and 24 where they got most of the information about sexual matters from and between 1990 and 2012 the proportion of people saying they got most information from school increased sizeably, so now about 40% of young adults are saying that’s where they get most of the information from and only a minority get the information from parents.Ìý However, 14% of women and 7% of men are saying that they didn’t know enough about sex when they had their first sexual experience, really saying they wanted more and better information.Ìý They also said they wanted more information about how to say no.Ìý And I think of concern was almost a quarter of men said they got some information about sex from pornography and these men in particular tended to say they got less information from school and also lacked some fairly basic information.

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Porter

And is there any difference in how they’re likely to behave as young sexually active adults, as they go forward, depending on when they were told?

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McCartney

Well the second paper goes some way to answering that.Ìý And this asked three and a half thousand men and women aged between 17 and 24 about where they got most of their information from about sex and what their first sexual experiences were like.Ìý And they basically found that the more young adults who got their information from school were more likely to have sex at an older age, they were also less likely to have non-volitional sex, abortion and distress and upset around sex.Ìý So in general terms it seems that better and more high quality information about sex at school resulted in people deferring the first stage of sexually intercourse.

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Porter

So if I’m very unscientific and I push both of those two pieces of research together one could conclude that there’s quite a significant proportion of people out there who felt that they should have learnt more at an earlier age and there is some evidence that the earlier you’re taught about these matters perhaps you’re more likely to behave responsibly later.

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McCartney

Yes and I think just giving people more confidence, better self-esteem, more ability to say no, more ability to say actually I’m going to put off my first sexual experience, I don’t feel ready for that for whatever reason.Ìý It’s important to note that these studies can’t prove cause and effect, they can only look for associations but basically I think that there’s lots of evidence accumulating that says that better information results in healthier young adults, more confident young adults and more young adults are able to put off when they first have sexual intercourse and that in itself is associated with a whole load of other health benefits.

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Porter

The other conclusion you might be forgiven for forming was that this is very much a job for schools, but where do parents sit in all of this?

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McCartney

Well I think parents should feel capable or able to give their children as much information as they want to but the bottom line is if you rely on parents to give children high quality information around about sex and relationships most children won’t get it.Ìý We know that only 7.1% of men and 14.1% of women said that they good information, the main source of information was from their parents and more people were purporting that they got most of their information from school.Ìý So I don’t think that parents should be put off giving information about children but if you want a reliable lesson plan, something that’s consistently taught and gives children skills in negotiation for example, it may be best to look for a formalised approach to that and if that can be delivered through schools then all the better.

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Porter

And Margaret do we have any evidence of harm, I’m wondering what could be the downside of telling a child perhaps before they’re ready?

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McCartney

It’s a really good point and I think in general terms unless you look for harms you don’t find them and I’m not aware that the sex education lessons have been through randomised control trials that you would do to get the high quality information about harms.Ìý However, when you look at the teenage pregnancy rate for example it has been going down and the under-18 conception rate in England is now at its lowest level since records began in 1969.Ìý So it certainly does not appear to be the case that earlier sexual education results or is associated with an increased rate of teenage pregnancy, so that’s one harm that does not seem to be happening.

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Porter

Reassuring for parents in that it would seem to suggest that early education does not generally encourage early sexual activity – which is what many parents worry about. Thank you very much Margaret. And there is more information on the new PHSE initiative on the Inside Health page of the Radio 4 website.

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Please do get in touch if there is an issue you would like us to look into. We are also keen to hear your feedback on the subjects we have already covered in the series. E-mail insidehealth@bbc.co.uk or send a tweet to @drmarkporter

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James e-mailed to ask about gallstones. He hasn’t actually got them yet, but a recent scan has shown that his gallbladder contains debris or sludge. Does that mean he is destined for trouble later?

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The gallbladder sits below the liver and acts as a reservoir for bile, which helps us digest fats. Stones are common. One in three women and one in six men will get them at some stage of their life and most will never cause any trouble, but some do go on to cause pain, and occasionally serious inflammation and infection. The only way to deal with stones is to remove the gallbladder, normally through keyhole surgery.

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James’s story is not that unusual in that debris or sludge, or even obvious stones, are often picked up on scans done for other reasons.

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Professor Hugh Barr is a Consultant Surgeon at Gloucestershire Hospitals NHS Trust.

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Barr

We’re finding it a lot more because the ultrasounds are very, very good and the ultra-sonographers can pick up debris, sludge in the gallbladder.Ìý It’s like muddy water with a few little granules in it.Ìý The question of course for James is what does this mean for me.Ìý Now usually we’ve done an ultrasound for symptoms – pain in the upper abdomen to the right over the gallbladder, vomiting, indigestion that there’s no other cause for – these are rather soft symptoms because they’re related to a lot of things.Ìý And it is challenging to advise patients when they have sludge and debris in the gallbladder.Ìý What I usually do is first of all to see if it goes away because we do not want to subject people to an operation unless they need it because bad things can occasionally happen.

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Porter

And what you mean by going away – the symptoms or the sludge?

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Barr

The sludge.Ìý We sometimes repeat it and the sludge looks clear.Ìý Now it may be a different machine and things like that but there’s no doubt that you can flush out sludge, I mean little stones can pass perhaps all the time.Ìý We’re a bit anxious about stones passing because they can cause jaundice and occasionally pancreatitis, now that can be really most unpleasant and if you’ve had an attack of pancreatitis we will be counselling you to have the gallbladder dealt with.

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Porter

And that’s because the pancreas sits basically – its outlet is in the same pipework as the gallbladder, so a blockage can affect that too?

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Barr

Absolutely, you’ve passed your anatomy exam.Ìý On occasion we find microlithiasis, that is little stones forming and that of course is the kernel for a bigger stone.

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Porter

What’s the latest thinking then on gallstones themselves?Ìý Say that James had had the classic symptoms, he’d had the scan and instead of showing debris, sludge, gravel – call it what you will – it had actually shown discrete marble sized stones for instance, would you then say to him look you should have these out?

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Barr

We ask the patient really how bad the symptoms are because you can control it by reducing your fats in your diet, Mediterranean diet’s very good, lots of fruit.Ìý But we will be offering them surgery – they need to consider surgery.Ìý Then we do have to run through the risks of what if surgery goes wrong and it does occasionally do so, it’s a very safe procedure done as a day case and we would therefore allow the patient to weigh up the risk/benefits with their families and if they’re young and troublesome then they usually go for it, some of the older patients say well in fact you know it’s not too bad and should I adjust my diet.Ìý We will advise patients before they have surgery to lose weight, so that we get them in a reasonable BMI, particularly because the fat deposits in the liver and the liver can be very congested and that sometimes helps dramatically.

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Porter

What happens if you leave stones, I mean what’s the worst case scenario other than pain?

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Barr

Well I’m afraid complications can occur in about two in 10, that is admission to hospital with the stone has travelled causing jaundice.Ìý It’s impacted in the gallbladder causing an inflamed very sore gallbladder requiring admission to hospital.

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Porter

But the 20% risk of having complications like that, that’s pretty high isn’t it, two out of 10 people are going on to get that, you can see why people go for the operation.

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Barr

That’s only for symptomatic gallstones.Ìý If, for example, you’re having an ultrasound because something else and you’ve had no problems then we can reassure you and say look actually these are not causing trouble but if you’ve got symptomatic gallstones then they can go on to give trouble.

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Porter

NICE has just produced updated guidance on managing gallstones and Hugh Barr’s colleague at Gloucester Royal, surgeon Simon Dwerryhouse, sat on the committee that produced it.

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Dwerryhouse

There were two areas that really we focused on and which we found good strong clinical evidence to support a change in practice.Ìý We found that patients who have a symptomatic gallstone, that is gallstones that are found on ultrasound scanning while a patient’s being investigated for another condition, do not need surgery.

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Porter

So they’ve not got any pain, they don’t know they’ve got them, but a doctor happens to find them?

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Dwerryhouse

Absolutely, we do not recommend surgery in that situation.Ìý The other area that we found strong evidence for was that patients presenting and requiring admission to hospital with acute gallbladder symptoms we would recommend now that they have surgery when they’re admitted to hospital.Ìý In the past a patient presenting acutely would often be kept in hospital, given painkillers and antibiotics until their symptoms had settled and then sent home to wait for a procedure or a surgery to be performed in a planned way six to eight weeks later.

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Porter

So they’d be told look this is due to your gallstones, we need to get you back in to get them out.

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Dwerryhouse

That’s absolutely right and this is almost making gallstones similar to the appendix in a way, if you come in with an acute gallbladder problem we should say you should have treatment there and then, much like we do with appendicitis.

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Porter

And that decision was based on what?

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Dwerryhouse

That was actually on clinical trials where people were either treated on their first admission or sent away for surgery at a later date.

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Porter

And one presumes that the outcome was better if you did it straightaway?

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Dwerryhouse

The outcome was better, it was shorter length of hospital stay, no increase in the potential risk of complications of the surgery.

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Porter

Because I remember being taught as a young medical student that the last thing a surgeon would want to do is to go in and operate on something that was inflamed and angry, it made your job more difficult.

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Dwerryhouse

That’s certainly a principle we still work by to a decree.Ìý It’s catching the inflammatory process at the correct stage, so if you operate within the first week of symptoms then actually the inflammation can sometimes be helpful in that the swelling around the gallbladder makes it almost easier to operate on.Ìý Beyond a week the inflammation can become very scarred and surgery at that time is more risky.Ìý So if a patient has presented with more than week of symptoms we would probably still follow the old fashioned course of letting their symptoms settle down and doing planned surgery at a later date.

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Porter

Surgeons Simon Dwerryhouse and Hugh Barr talking to me at Gloucestershire Royal Hospital. And there is a link to the new NICE guidance on our website.

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Now the number of people opting for cosmetic surgery has taken an unexpected downward turn, according to the latest audit of members of The British Association of Aesthetic Plastic Surgeons who perform a third of all operations in the UK.

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Breast augmentation still topped the list of most common procedures in 2014 but numbers were down by 23% on the previous year.

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Demand remained flat for the next three most common operations - eyelid surgery, face and neck lifts and breast reductions – but nose jobs slipped 24%.Ìý Overall the total number of procedures was down nearly 10%.

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But what is behind the fall?

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Simon Withey is Consultant Plastic Surgeon at the Royal Free Hospital in London.

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Withey

The message is that there has been a reduction in patients undergoing aesthetic surgery.Ìý In some areas reductions of up to 25 or 30% would seem that there’s been a dramatic change in the way patients are behaving, breast surgery and male patients seeking rhinoplasty surgery to alter the shape of someone’s nose.Ìý The trouble is trying to decide whether that’s patients’ planning surgery and decide that it’s not in their best interests or whether it’s patients who are going elsewhere for their surgery or whether it’s patients who have financial difficulties, it’s still at the tail end of the credit crisis, there are patients I think still finding it difficult to raise the funds, deciding which of those is actually influencing these numbers is difficult.Ìý So the news is good news if it is that people are taking a more considered approach to this and are thinking more carefully and in some cases are deciding that it’s not right for them and patients are wiser and better informed.Ìý It’s perhaps less good news if it means that patients are choosing a cheaper or less reputable less experienced option.Ìý I’m an optimist so I hope it’s that patients are becoming better informed and are making more considered and careful decisions.

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Porter

Simon Withey.Ìý Another factor could be that some women have been put off implants by the PIP scandal of 2012 where the wrong type of silicone was used by one manufacturer. But, paradoxically, demand here in the UK actually rose the year after PIP implants were in the news. So something else must be going on.

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Two sets of figures from American societies have just been released too and while they don’t reveal such a drop, demand for breast implants has fallen slightly there too. Michael Edwards is President of the American Society of Aesthetic Plastic Surgeons and spoke to me down the line from Las Vegas. Might the PIP scandal have affected confidence there?

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Edwards

Actually no, the PIP implants, the gel implants, were never approved in the US so I have seen a few patients that had them put in internationally but across the US that certainly is something that didn’t hit us.Ìý

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Porter

So why do you think demand is flat in America with regard to breast augmentation in particular?

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Edwards

Interesting, I don’t know that if you would look at my practice that certainly would not be the case and if I talk to other colleagues and if you would talk to the implant manufacturers they would say that their sales are certainly up and growing.Ìý So I’m not quite sure how to correlate the two differences.Ìý I would still say that to get true numbers for every plastic surgeon that operated in the US you’d find that the numbers were probably up.

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Glasberg

My name is Dr Scot Glasberg, I’m from New York and I’m the President of the American Society of Plastic Surgeons.Ìý I think that in terms of breast augmentation I would agree that the numbers are relatively flat, may be down a tick.

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Porter

Are you noticing a change in the sort of procedures that your patients are asking for?

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Glasberg

So I think minimally and basic continues to grow, namely the Botex and the fillers.Ìý I think that some women and men are getting it younger and younger.Ìý The other thing we’re seeing is a bit of a transition to other types of procedures which are starting to take off.Ìý Buttock augmentation is really the big one right now.Ìý And I think two things have happened there, I think the media and how it presented celebrities to the public where a butt is in, meaning it’s fashionable to have a larger buttock right now, so patients are asking for that more and more and that’s driving part of it.Ìý I think the other thing that’s happened is the technology has changed dramatically, no longer are we simply reliant on implants for buttock augmentation but we’re actually going to fat grafting and fat grafting as you may or may not know is one of the single largest exponentially growing elements of plastic surgery across the board.

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Porter

And that put simply is taking fat from one part of the patient and putting it into another part?

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Glasberg

Exactly.Ìý Inevitably that’s going to yield a more natural result than any implant ever could.Ìý The last area where we’ve seen some significant growth is in men and the acceptance of men of plastic surgery has continued to grow, the mythical element that it’s only for women is being shut down by both the media and just general word of mouth.Ìý The other thing is I’m seeing much more of a request by patients for subtleness, subtlety in their results.Ìý They don’t want to look pulled when they get a facelift, they don’t want a huge dramatic change in a rhinoplasty, they want people to look at them and say hey you look like you slept better, perhaps you look like you took a vacation, you look rested.Ìý Not hey wow you’ve had this particular plastic surgery procedure.

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Porter

Dr Scot Glasberg talking to me from New York. Does my bum look big in this - is obviously so last season!Ìý You heard it here first.

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And talking of bottoms, next week I visit a university lab where a team has created an artificial bowel to study the billions of bacteria that live inside us, bacteria that researchers now believe can influence everything from immunity to our weight.Ìý It will change the way you think about your insides.

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ENDS