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mediated generation of free radicals and augment the bradykinin-induced activation of nitric oxide. Quinapril hydrochloride has ashort half-life and a potent binding capacity for both plasma andtissue ACE. There are as yet no data on whether the lipophilicityand tissue binding capacity of quinapril make it uniquely capableof improving endothelial function. Other ACE inhibitors wouldtherefore require further testing before the results of the TRENDstudy can be extended to them.The improvement in endothelial dysfunction by ACE inhibi-

tors may explain the effects of ACE inhibitors in reducing thenumber of ischaemic events and need for revascularization in theSAVE and SOLVD studies of ACE inhibitors in left ventriculardysfunction. In these studies, the benefit may have partially beendue to the improvement in left ventricular function. This studysuggests that some of the benefit may be due to improvement inendothelial function. This hypothesis is being tested in the quinaprilischaemic event trial (QUIET), a 3-year trial to assess the abilityof quinapril to reduce ischaemic events in patients with estab-lished coronary artery disease and preserved left ventricularfunction. TREND is the first study to provide a new pathophysio-logical rationale for the use of ACE inhibitors in patients ofcoronary artery disease with normal left ventricular function.

REFERENCESRubanyi GM. The role of endothelium in cardiovascular homeostatis and diseases.J Cardiovasc Pharmaco11993;22 (SuppI4):IS-14S.

2 Vanhoutte PM. Endothelium and responsiveness of vascular smooth muscle. JHypertens Supp11987;5 (Suppl 5): II S-20S.

3 Harrison DG. Endothelial dysfunction in atherosclerosis. Basic Res Cardiol1994;89 (Suppl 1):87-102.

Cigarette smoking in China-A messagefor India

Yuan J-M, Ross RK, Wang X-L, Gao Y-T, Henderson BE, YuMe. (Shanghai Cancer Institute, Shanghai, China; USClNorrisComprehensive Cancer Center, University of Southern Califor-nia, Los Angeles, California, USA.) Morbidity and mortality inrelation to cigarette smoking in Shanghai, China-A prospectivecohort study. lAMA 1995;275: 1646-50.

SUMMARYThis is a report from China of a prospective cohort study of 18 244men, aged 45-64 years, who were followed up for a mean of 5.4years. About 80% of the men residing in four geographic areas in thecity of Shanghai responded to an invitation to enrol in the study. Therecruitment took place between 1 January 1986 and 30 September1989, and the cut-off date for follow up was 30 September 1993.Thefollow up percentage was 99.7% and a total of 98267 man-yearsaccrued. Follow up was carried out for mortality with specific causeof death and for incidence of cases of cancer through a population-based cancer registry. Details of the follow up procedure werepublished elsewhere.At baseline, about 50% of men were reported to be current

smokers and 7% ex-smokers. About half the current smokerssmokedmore than 20 cigarettes a day. In general, those who started smoking

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 10, NO.2, 1997

4 Chobanian AV, Haudenschild CC, Nickerson C, Drago R. Antiatherogenic effectof captopril in the Watanabe heritable hyperlipidemic rabbit. Hypertension 1990;15:327-31.

5 Vanhoutte PM, Auch-Schwelk W, Biondi ML, Lorenz RR, Schini VB, Vidal MJ.Why are converting enzyme inhibitors vasodilators? Br I Clin Pharmacol1989;28:95S-I04S.

6 Griendling KK, Minieri CA, Ollerenshaw 10, Alexander RW. Angiotensin IIstimulates NADH and NADPH oxidase activity in cultured vascular smooth musclecells. Circ Res 1994;74:1141-8.

7 Yusuf S, Pepine CJ, Garces C, Pouleur H, Salem D, Kostis J, et al. Effect ofenalapril on myocardial infarction and unstable angina in patients with low ejectionfractions. Lancet 1992;340: 1173-8.

8 Pfeffer MA, Braunwald E, Moye LA, Basta L, Brown EJ Jr, Cuddy TE, et al. Effectof captopril on mortality and morbidity in patients with left ventricular dysfunctionafter myocardial infarction: Results of the survival and ventricular enlargementtrial. The SAVE investigators. N Engl] Med 1992;327:669-77.

9 Daemen MJAP, Lombardi DM, Bosman Fl', Schwartz SM. Angiotensin II inducessmooth muscle cell proliferation in the normal and injured rat arterial wall. Circ Res1991 ;68:450--6.

10 Dawkin R, Purcell TS. Investigator 's brochure: Quinapril hydrochloride (C1·906).Ann Arbor, Michigan:Parke-Davis, 1989.

II Lonn EM, Yusuf S, Jha P, Montague TJ, Teo KK, Benedict CR, Pitt B. Emergingrole of angiotensin-converting enzyme inhibitors in cardiac and vascular protection.Circulation 1994;90:205~9.

12 Texter M, Lees RS, Pitt B, Dinsmore RE, Uprichard ACG. The quinapril ischemicevent trial (QUIET) design and methods: Evaluation of chronic ACE inhibitortherapy after coronary artery intervention. Cardiovasc Drugs Ther 1993;7:273-82.

SANDEEP SETHDepartment of Cardiology

ALLADI MOHANDepartment of Medicine

All India Institute of Medical SciencesNew Delhi

at an early age were heavier smokers. Ex-smokers had given upsmoking about 8 years before the start of the study but did not differfrom current smokers in the age at which they started smoking,number of cigarettes smoked per day and the duration of smoking.Being in small numbers, ex-smokers were excluded from analysis.Cigarette smoking was significantly associated with an overall

increased risk of cancer (relative risk, RR 1.9); the most important ofthese were cancers ofthe lung (RR 6.5) and head and neck (RR 5.2)-both had a significant dose-response relationship. A negative asso-ciation with age at starting smoking was also significant. All-causemortality was significantly higher among smokers (RR 1.4)and apartfrom cancer that accounted for the largest proportion (41%) of alldeaths, mortality was significantly higher for ischaemic heart disease(RR 2.0), other heart disease (RR 2.4) and chronic obstructivepulmonary disease (RR 1.4).Overall mortality was somewhat lowerduring the first year of enrolment and was explained by the exclusionof terminally ill patients from the cohort. Overall, 21% of the all-cause mortality and 36% of the cancer incidence could be attributedto cigarette smoking.An important variable that independently affected the magnitude

of the RR was the age at which smoking was started. The studyrevealed that older men started smoking at later ages compared toyounger men who started smoking earlier and were smoking a highernumber of cigarettes per day. Based on these patterns, it was pre-dicted that the smoking-attributable mortality would rise further.

COMMENTThe findings reported in this paper are neither novel nor surpris-

SELECTED SUMMARIES

ing. The relationship between cigarette smoking and variousdiseases has been reported from all over the world during the lastfour decades. The magnitude of the various relative risks is alsonot very different from earlier reports. In essence. the study onlyhelps in establishing the fact that as far as health effects ofcigarette smoking are concerned. Chinese are not much differentfrom Caucasians.Although the paper may not have reported a startling new

finding. it is nevertheless extremely important. If the availabilityof scientific data and knowledge about cigarette smoking as themajor cause of lung cancer was enough to control the disease. weshould have had very few deaths from lung cancer 30 years afterobtaining the information. However, lung cancer deaths world-wide are continuing to increase. Every health organization agreesthat smoking is the most preventable cause of adult death anddisease in the world. yet smoking worldwide is rising.The reasons are not difficult to find. The smoking epidemic

and the health consequences arising from it can be controlled onlythrough actions by the sovereign government of a country. Giventhe large economic and other dimensions ofthe tobacco problem.

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it is clear that scientific knowledge is simply not sufficient toinduce adequate tobacco control measures.China is the most populous country in the world and is

projected to suffer from a large load of smoking-attributabledeaths in the near future. So far, such projections have been basedon international data. This report is the first of its kind not onlyfrom China but from mainland Asia. Although China has alreadyembarked upon an ambitious tobacco control programme, theprojections based completely on Chinese data can be expected tohave a more powerful impact.In addition to being the two most populous countries. China

and India are among the largest producers and consumers oftobacco in the world. Specific tobacco control measures in onecountry, therefore. would not go completely unnoticed in theother.

P. C. GUPTATata Institute of Fundamental Research

MumbaiMaharashtra

ObituariesMany doctors in India practise medicine in difficult areas under tryingcircumstances and resist the attraction of better prospects in western coun-tries and in the Middle East. They die without their contributions to ourcountry being acknowledged.

The National Medical Journal of India wishes to recognize the efforts ofthese doctors. We invite short accounts of the life and work of a recentlydeceased colleague by a friend, student or relative. The account in about500 to 1000 words should describe his or her education and training andhighlight the achievements as well as disappointments. A photographshould accompany the obituary.

-Editor