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Anti-smoking incentives, ACE inhibitor cough, Raynaud's, fizzy drinks

Duration:
28 minutes
First broadcast:
Tuesday 21 February 2012

Dr Mark Porter demystifies the health issues that perplex us and separates the facts from the fiction. He brings clarity to conflicting health advice, explores new medical research and tackles the big health issue of the moment revealing the inner workings of the medical profession and the daily dilemmas doctors face.

As new figures published show that 1 in 7 women in England continue to smoke during pregnancy, Inside Health investigates a pilot incentive scheme - which gives women just over £750 worth of vouchers if they give up, and stay off cigarettes for at least 6 months after they give birth. What is the evidence that these incentive schemes work?

And what about incentives encouraging doctors to ask whether a patient smokes, or check their blood pressure and cholesterol levels. Dr Margaret McCartney explains why she is one of many GPs who are uncomfortable with the way incentives can influence practice

Plus if you've been plagued by a recurring dry tickly cough, it could be caused by a widely used family of blood pressure drug - the ACE inhibitors. Mark Porter investigates.

And although it's been slightly warmer that's likely to be cold comfort for 10 million people in the UK with Raynaud's disease where the fingers turn ghostly white after exposure to temperature changes .

Presenter: Dr Mark Porter
Producer: Erika Wright.

  • Rosie Toon's hand with Raynaud's

    Rosie Toon's hand with Raynaud's

  • Programme Transcript - Inside Health

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX: 21.02.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: ERIKA WRIGHT



    Porter
    Hello and welcome to Inside Health. In today's programme: Prevention may be better than cure, but it often comes at a price - could your cough be caused by something your GP's prescribed?

    Clip
    My big worry is that by medicating people unnecessarily we are adding to the side effect burden that they're having.

    So it's quite possible that somebody comes to see me, they get put on something to treat their blood pressure and they end up on something for their blood pressure and something for their cough, which was caused by the blood pressure tablet I gave them?

    Absolutely I have seen that so many times.

    Porter
    And although the weather has got a bit warmer recently, that is likely to be cold comfort for those of you with Raynaud's - I will investigating a condition now thought to affect up to10 million people in the UK.

    But first smoking and pregnancy - new figures published by the NHS Information Centre this week show that one in seven women in England continues to smoke during pregnancy, and there is a huge North South divide with pregnant women in Blackpool 10 times more likely to smoke than those from Brent in London.

    Researchers are investigating a controversial approach to tackling the problem - paying women to quit. But bribing people to be healthier hasn't always gone down well.

    News headlines
    Mums to be paid to quit.

    Staying healthy should be enough of an incentive for people to come in for testing; they shouldn't need to be bribed.

    Why is this society so hell bent on rewarding the least deserving?

    Porter
    The latest incentive scheme - which gives women just over £750 worth of vouchers if they give up and stay off cigarettes for at least six months after they give birth - is being piloted in Derbyshire by Theresa Marteau, Professor of Health Psychology at King's College in London.

    Marteau
    We start off by offering a small incentive, relatively frequently, so women have four tests in the first two weeks of their quit attempt and the vouchers increase in value, so they start off with the first test that they attend the vouchers are worth £8 and then they increase in value by £1 each time they come along for a test.

    Porter
    And by test you're doing breath tests on them or how are you....?

    Marteau
    Yes, yes no that's absolutely right. So women in the first seven weeks they are visited at home by a support worker and if the woman reports that she hasn't been smoking and she has a breath test that shows that she hasn't been smoking then she wins the incentive.

    Porter
    What's the evidence behind such an incentive, and in particular is there any evidence in the way that you've structured it - starting low and getting higher as they go throughout the pregnancy?

    Marteau
    What we've done is we've modelled the incentive structure on the ones that have been found in three trials that have been conducted in the US that have shown surprisingly effective results in pregnant women. Now smoking in pregnancy is a major public health problem and a recent review of the role by literature which looked at 72 trials found that while there was modest effectiveness for what are now standard treatments in England the trials that had been conducted in the US of financial incentives were seemingly significantly more effective than everything else that was being looked at. So we thought it was worth a go.

    Porter
    How's it been received locally in Derbyshire?

    Marteau
    The initial response, I would say, has been mixed but we've not been surprised because these are controversial schemes.

    Porter
    Yes, I mean I had a look on the internet, I looked at the letters page of the Derbyshire Times, and there was suggestion there amongst some of their correspondents that pregnancy itself should be a big enough incentive.

    Marteau
    Well sometimes it is and for many women they are able to stop smoking because they're pregnant and that's fantastic. But for many women it isn't enough. Women who smoke throughout pregnancy are generally poorer, lower levels of education, lower social support, more likely to be depressed and have other psychological problems. We also know that living in poverty makes it more difficult to act thinking about future gains, you're much more present oriented. And this is one of the features of financial incentives - what you're doing is you're providing someone with a certain reward that's immediate.

    Porter
    How's this been received in the wider community amongst your colleagues, for instance, this concept that we're effectively - I mean it's incentivising or bribing patients to behave as we'd like them to behave?

    Marteau
    It's - it's controversial not just amongst the general public but amongst healthcare professionals as well. And I think the concerns are - well firstly people are pretty sceptical that it can be effective and there are concerns that it might generate harm, that it might - technically what people have talked about is crowd out intrinsic or internal motivation for people to make changes.

    Porter
    What do you mean by crowd out?

    Marteau
    Well what it means is if you start offering people money they will do things to follow the money but not do them because they want to do them. The other component of this is one of the main criticisms that has been levelled at incentive schemes is that it can encourage gaining or cheating, if you like. So people have been concerned that well maybe people will take up smoking to qualify for a scheme or people will carry on smoking but manage somehow to cheat the test in order to qualify for the vouchers. So what we're doing, as part of our pilot, is trying to get a handle on that. We doubt that this is something that's very common but nonetheless we do want to get a sense of this because if it is relatively common then of course that would lead to an inflated estimate as to how effective these schemes can be.

    Porter
    Theresa if things go according to plan what sort of success rate would you be happy with?

    Marteau
    We've predicted conservatively that offering the financial incentive scheme in Chesterfield could result in as many as 12% of women stopping smoking and we're offering the scheme both during pregnancy and for six months after pregnancy and we're comparing that with a background rate of 6%. So we're hoping we may double the quit rate if things go according to plan.

    Porter
    Professor Theresa Marteau with a tacit reminder of how hard it is to get people to give up smoking - even if the voucher incentives double the number who quit, seven out of eight smokers will still carry on regardless.

    Kamran Abbasi - Editor of the Journal of The Royal Society of Medicine and our resident sceptic has been looking at moves to cut the number of people who smoke.

    The latest of which Kamran, in the news this week, is a move to plain packaging? It's prompted quite a lot of debate.

    Abbasi
    Yes it has. In fact the debate is how much research is there about this and in fact there's over 20 years' worth of research - and that's global research, in many different countries. The World Health Organisation produced a document in the last decade called the framework convention on tobacco control, which is a major initiative by WHO and that recommended plain packaging and the EU have signed up to that document. So...

    Porter
    Based on what principles though - how's it going to work?

    Abbasi
    There are three basic principles. The first is that by having plain packaging we increase the effectiveness of health warnings on cigarette packs, so all you see is the health warning, you don't see the branding for the manufacturer...

    Porter
    They stand out.

    Abbasi
    Yeah exactly. Secondly, it reduces what we call false health beliefs about cigarettes and what that means is that because there are certain words used on certain cigarette packets, certain colours used, so words like smooth, colours like gold and silver, they suggest to people in market research that cigarettes within those packs are less harmful when of course they aren't. So it reduces these false health beliefs and thirdly it - with no branding on the packs - it reduces the appeal to young people to start smoking and fundamentally that's what the whole initiative is all about.

    Porter
    Thank you very much Kamran.

    Well we've talked about using financial incentives to help smokers, but what about using them to encourage doctors to ask whether a patient smokes, or perhaps check their blood pressure or cholesterol levels?

    One infamous medical cartoon neatly summed up what some GPs think of such incentives. It showed a man sitting opposite his doctor with a large axe sticking out of his back, and a trail of blood across the consulting room floor, where the chap had obviously dragged himself in to ask for his GP's help. Meanwhile the doctor is glued to his computer screen and, without looking up, simply says: "We'll get on to your back pain in a moment, but first do you smoke?".

    Dr Margaret McCartney is one of many GPs who are uncomfortable with the way incentives can influence practice.

    McCartney
    When you go to your GP you think it's a private consultation, but wait - look carefully, for there is a
    politician sitting there too. The GP looks at the computer, and wants to know: Are you still smoking? Have you considered long-acting contraception? Is your smear up to date? What's your weight - and can you just roll up your sleeve - we need an up to date blood pressure....?

    These questions have political fingerprints, and push into this most sensitive of spaces. That silent third person drives a lot - too much - of what doctors do. Each of these questions gets points for the GP contract, which was negotiated between the British Medical Association and the government. Points mean prizes - money for reaching targets - and change annually. Clinics have their points published and negative inferences are made about low scores. So the pressure is on.

    The idea was to use evidence to drive practice. There's research that when doctors ask patients if they would like help in stopping smoking, some people will then give up. But sometimes it is simply inappropriate to nag someone about smoking when there are more pressing concerns. I've even come across scenarios where a person has put off seeking help about a symptom over fears that they will also be scolded - sorry - offered advice - about being overweight, for example.

    The automation of consultations into a strictly contract arrangement is bad for patients - and bad for doctors. I am deprofessionalised, stripped of my vocation, stopped from being a listening and responsive doctor, hearing and interacting in a human relationship. But low scores could make it look as though I am a bad doctor. It's easy to see how my priorities could be conflicted, and easily skewed into generating neatly ticked contract boxes.

    It's just as bad for patients. Their priorities - treating a skin problem or discussing a mental illness - competes with doctor priorities that is the tick boxes for their contract. The patient is less of an individual with unique concerns. It means healthcare becomes industrialized. There's even evidence
    that some contract work - like routine symptom scores in depression - do not make better decisions and are paper chasing wastes of time.

    So, if not political contracts, who should decide what doctors do? Here's an idea. Patients working with doctors who are professionally motivated not financially driven.
    Porter
    Dr Margaret McCartney. And those incentives can have another knock on effect too. The current drive to screen and medicate outwardly otherwise fit and healthy patients because of problems like high cholesterol levels, or raised blood pressure has led to many more people taking preventative medicines and, as with all medicines, there is a downside. In the case of one widely used family of blood pressure treatment - the ACE inhibitors - it can be a surprisingly annoying cough. As Nick Fowler discovered.

    Fowler
    I got a cold in the winter and the cough stuck with me for at least four months and quite frankly it was keeping me awake at night - a very dry, ticklish cough, day and night. So I went to my own GP who said I can't really find anything wrong I'll refer you to a specialist. I went to the specialist, you obviously start to have concerns, could it be something rather major. And he said: "Do you know what pills you're taking?" And he said: "That's the one, you taking that for blood pressure?" I said: "Yes." He said: "I think that's probably the cause of it." Within a couple of days I was on a different tablet and a few weeks, perhaps a month or so later, the cough had gone, so it seemed to be the magic trick.

    Porter
    Millions of people take ACE inhibitors like ramipril, perindopril and lisinopril and coughs like Nick's are a common complaint, but one that is often ignored - or forgotten. Dr Richard Russell is a consultant chest physician at Heatherwood and Wexham Park Hospital.

    Russell
    In 5-10% of people they actually do cause a cough and that can range from a minor little tickle to something which is fairly debilitating. Many people listening will have had a long term cough and it drives you up the wall - I've had one myself and I wanted to cut my head off after two months and realistically mean that. Cough can be extremely debilitating and cause incontinence, can cause fainting - and I had a patient just last week with what we call cough syncope - every time he coughed, a big spasm of coughing, he would faint.

    Porter
    So let's look at the timing - if I start - started one of these drugs, let's say ramipril, one of the most widely used versions, how soon after starting the drug is a cough likely to develop and what's that cough typically like?

    Russell
    It's very, very variable and that's one of the problems, it can occur very quickly and for example I had a lady this morning had got asthma she was started on one of these drugs and within a couple of days was actually feeling a very tickly cough but it can be several months later. It is usually dry, it is unrelenting, it's usually not there at night, interestingly, it's easily identified and obviously stopping the medication cures it. But people need to remember that stopping a medication the cough can last six weeks or more after that medication's been stopped and it doesn't have many triggers - it's a really annoying little dry cough.

    Porter
    And you're saying it doesn't settle necessarily when you stop the medication?

    Russell
    Not immediately and one of the mistakes that gets made sometimes is that people stop the medication, expect it to go away, no you need to wait for up to two months for that effect to go away.

    Morice
    The doctor often in his letter will say it can't be the ACE inhibitor because I've stopped it for a month and the cough hasn't gone away and that's not true.

    Porter
    Alyn Morice is Professor of Respiratory Medicine at the University of Hull and argues that, while it is important to treat high blood pressure, incentives for doctors are part of the reason why this kind of cough is so common - and on the increase.

    Morice
    What the drug does is make your cough reflex more sensitive, so it doesn't actually give you a cough, it just makes the nerves in your throat more sensitive, so you might have it for a week, a month, two months and start coughing and then also because it resets the cough reflex it takes a long time for the drug to wear off.

    Porter
    Alyn, one of the issues here is that doctors like me part of our targets, the way that we get remunerated, the way our practices are funded...

    Morice
    The way you're paid.

    Porter
    The way you're paid, yeah, is on performance - how good we are at lowering cholesterol, lowering blood pressure, getting people with diabetes to target - and that involves using, invariably, these drugs.

    Morice
    It is the main driver that people are very keen to get their quota of patients up to the necessary level to get the full remuneration. But really what you need to do is look at that individual and say does that individual have the risk factors. So, for example, ladies are far less at risk than men and yet a fifth of non-smoking ladies are put on these drugs.

    Porter
    No I mean to be fair to any GPs listening it's not just - I don't see you every time you walk into my surgery, if you're my patient, I wouldn't see you purely as a cash cow, I mean there is this belief that you're doing the right thing as well, supposedly, do you think we're underestimating the impact that it has and we should be actually looking more for side effects, not just looking in terms of what's happening with the blood pressure but how do you feel?

    Morice
    High blood pressure - I don't have much problem with. If your blood pressure is high you have a disease which you don't recognise, so if you do have high blood pressure then that's true. But treating lipids, fat...

    Porter
    High cholesterol.

    Morice
    High cholesterol is often, in people who are well, not very well evidenced at all.

    Porter
    And actually in the case of this family of drugs - the ACE inhibitors - you can have your cake and eat it if you want to remain on these you can swap to other medicines.

    Morice
    Yeah there's an A2 inhibitor, as they're called, which doesn't have the side effect of cough.

    Porter
    A sort of son of ACE inhibitors.

    Morice
    Yes they're just a bit more expensive because they're not off patent yet.

    Porter
    So that's why we use the cheaper cough causing ones first in the hope...

    Morice
    Correct. My big worry is that what we're doing in modern society is treating a lot of well people in the hope that they might have a preventative effect but in fact their risk is so small there is very little benefit.

    Porter
    The argument being that if you're at very low risk and you halve that very low risk it's still very low risk so you've not got much gain?

    Morice
    Yes. Half of bugger all is bugger all.

    Porter
    Plain speaking Professor Alyn Morice reminding us, lest we forget, that prescribing can have downsides as well as upsides.

    If there is an health issue that confuses you, and you would like us to investigate and clarify, then do please get in touch by e-mailing insidehealth@bbc.co.uk or sending a tweet containing the hashtag insidehealth to @bbcradio4 .

    Now, how many fizzy drinks do you, your children, or your grandchildren, drink in a week?

    Vox Pops
    I try not to have too many of them, probably one or two bottles a week of 500ml.

    I don't like fizzy drinks really.

    I do.

    You do?

    My kids do.

    I like fizzy drinks.

    What do you like about fizzy drinks?

    They make me crazy.

    They make you crazy? That's good is it?

    Yeah.

    Any other effects?

    I think they make me windy.

    They make you windy?

    Yes.

    So if I said to you fizzy drinks, from a health perspective, what's the first sort of thing that comes to your mind?

    Not very healthy.

    Do you drink them?

    Of course.

    Are they good for you?

    I don't think so.

    Why?

    I think because all of the sugar, caffeine.

    But you still drink them?

    Of course.

    They taste nice, okay. Thanks very much, cheers guys.

    Porter
    So the public perception - not surprisingly - is that they are bad for our teeth and waistlines, but recent research suggests there might be much more to them than that. A growing number of studies are linking fizzy drink consumption to a diverse range of issues, ranging from behavioural problems, to heart disease and osteoporosis. With new research out this month suggesting that soft drinks, including fizzy drinks, may even increase the chances of developing asthma.

    Kamran Abbasi has been looking into the hazards of fizzy drinks, Kamran what did you find?

    Abbasi
    Well what I found was that considering the size of the problem in terms of there are billions of soft drinks consumed every year there isn't that much research looking into the potential hazards and certainly not very good quality research. So the first lesson is that there has to be better research and we probably need a very thorough review of the area. Now the links that have been suggested are one, the obvious link with obesity, which I think we can be reasonably confident about. And then there are other areas such as issues with thinning of the bones like osteo - the condition called osteoporosis, there are cardiovascular consequences potentially, such as high blood pressure, also there is a potential link with diabetes and a more recent finding which suggests that there may be a link with asthma which turns out to be a rather small study, which cannot prove that there's a link between asthma and fizzy drinks, so that's got a bit of a way to go I think.

    Porter
    Is it something about the drinks that's to blame or is this telling us something about the people who drink them?

    Abbasi
    Yeah I think that's the heart of the matter - the big question is is it lifestyle, is it something to do with the way people behave outside drinking soft and fizzy drinks or is it something within the drinks themselves that's causing these potential health problems? Some of this evidence suggests that it's a mixture of the two and if we take the example of thinning of the bones - osteoporosis, I think that's quite a good example that perhaps leads us to the answer - so a link's been suggested between fizzy drinks and osteoporosis and there are two potential reasons for this. One is that because people are drinking soft drinks they don't drink milk and they don't take in other nutrients like calcium...

    Porter
    They're substituting a relatively unhealthy food for things that are essential for good bone health?

    Abbasi
    Yeah precisely, which is a proxy for a poorer lifestyle. So that's one explanation. But when studies take that into account they - what we call - adjust for lifestyle we still find an effect, we still find that fizzy drinks potentially cause some thinning of the bones and why is that - there are a couple of potential reasons for that - one is that fizzy drinks contain something called phosphoric acid and the phosphorous in that can end up causing bone loss because it competes with the calcium and secondly there's been a role suggested of caffeine in fizzy drinks which affects calcium absorption. So if we take the example of osteoporosis that suggests it's a bit of both and I think that's the answer - there are two explanations.

    Porter
    Do we have any idea from what research is out there in terms of what we should be limiting our intake to for optimum health?

    Abbasi
    No we don't, I think the research that's out there the conclusions tend to be we should drink less, that's an obvious thing to say - yeah we should always drink less. But I think this shows that there's a dearth of research and clear guidance and one of the - I think - the initiatives that needs to be taken on and reasonably quickly is to say well what should we be doing and what safe and how - what are the risks associated with fizzy drinks.

    Porter
    Kamran Abbasi as always more research needed - thank you very much.

    Now on to another consequence of drinking fizzy drinks - albeit an indirect one linked to the fact that they taste best cold.

    Toon
    My name's Rosie Toon, I'm a physiotherapist and I've had Raynauds since I was a teenager.

    Porter
    Well we're standing on a cool evening in Millennium Square in the middle of Bristol with a gin and tonic here and your hands have gone. Just describe to us what that feels like.

    Toon
    Well the palm of my hand's still quite nice and pink but my fingers, all the way down to my knuckle, has now gone white because - they just look like dead fingers really.

    Porter
    Well they look like dead person's fingers yeah.

    Toon
    Yeah it is quite dramatic I think when people see it if they haven't seen it before.

    Porter
    Getting it when you touch gin and tonic's not the end of the world but how else does it affect you?

    Toon
    Going into the supermarket down the refrigerated aisles.

    Porter
    That's enough to trigger it off is it?

    Toon
    Yes, yes, picking up a pint of milk then would be a nightmare and then trying to get to the till then and open my purse, getting out coins out is quite fiddly.

    Porter
    Raynaud's phenomenon is thought to affect around 10 million people in the UK, most of them women like Rosie. It get its name from Maurice Raynaud, the French physician who first described the characteristic changes over a 150 years ago, but we are still none the wiser as to why so many people are troubled by it. Anne Mawdsley is the Chief Executive of the Raynaud's and Scleroderma Association.

    Mawdsley
    We still don't know the cause. They're looking at the fact that a. the blood may be a bit too thick to get through to the small blood vessels or the small vessels are too small to let the blood flow through.

    Porter
    And by blood vessels, Anne, you mean the small blood vessels supplying the extremities - the toes and the fingers?

    Mawdsley
    Yes that's right. The blood vessels actually shut down and they stop the blood getting there, so there's a message going from the brain which is telling the body that it's very cold and therefore it's just shutting down those vessels and preventing the blood on a temporary basis from getting to the extremities. And one of the worst things, which I find, and I know a lot of other people find, is air conditioning, cold air blowing down, and that really can cause a problem.

    Porter
    So it's not so much the absolute temperature it's the change in temperature that can precipitate....

    Mawdsley
    Yes you can be on a hot beach in Spain or somewhere and you get the cold wind blowing and that's enough to spark an attack.

    Toon
    The worst case is if I'm on holiday in the summer and I've been sitting by the pool reading my book or something and then I get up and dive into the swimming pool, then that will be a nightmare, it is excruciatingly painful then and I would just have to get straight out.

    Porter
    What would happen now if we were to go back inside the bar here, how long would it take before your hands would turn to normal?

    Toon
    About 15 minutes.

    Porter
    And it just gradually returns?

    Toon
    No it can be quite dramatic, so that if I shake my hands then I get a very definite demarcation line between the white and the red and then they might go a little bit blue where the blood just starts to come back in.

    Porter
    What about emotion?

    Toon
    If I'm a bit stressed or anxiety - yes, I would say that does it make it 10 times worse.

    Mawdsley
    Stress can also cause the problem, it's like the fight and flight reaction, you know, where somebody suddenly gets a shock of some description or we get calls from people who've maybe have had a bereavement and that has made their Raynaud's worse, it doesn't necessarily mean it's actually caused the condition, it's if you've got the condition and you're then put under stress it can make it worse.

    Porter
    What can people do to help themselves?

    Mawdsley
    I think in the first instance if you go along to a GP because your Raynaud's is more than just a nuisance then hopefully a GP would give you a blood test which would help not to diagnose the condition but to tell you whether or not you've got an underlying condition, so that really is the first thing.

    Porter
    And that test is likely to be normal but it's worth looking for an underlying cause. Assuming that there isn't an underlying cause what's the next step?

    Mawdsley
    It is definitely self-help because we know that heat is very important, one shouldn't put one's hands onto a radiator or into hot water but just luke warm water alternating with cool water can help and there are many, many heating aids - heated clothing - lots of things that people can do. And one of the main things to remember is that you need to keep the trunk of the body warm because it's the major organs that are really important to be kept warm if you're going to keep the extremities warm.

    Porter
    What happens if keeping my extremities warm doesn't do the trick, what's the next step?

    Mawdsley
    Doctors can prescribe certain medications now, there are also complementary therapies - things such as ginkgo baloba, garlic - things that will actually help to improve the circulation.

    Porter
    The ginkgo baloba and the garlic - you often read about these - is there actually any hard evidence that they work?

    Mawdsley
    There have been studies done certainly on ginkgo baloba, there was a study that was done in Dundee which showed that the ginkgo reduced the number of attacks that people had with Raynaud's and it did have quite a substantial improvement.

    Porter
    Anne Mawdsley - and there is a link on our website to more details of the underlying conditions - like scleroderma and rheumatoid arthritis - that are sometimes associated with Raynaud's, as well as details of the various treatments available and a picture of Rosie Toon's hand after clutching that cold drink in Bristol. Go to bbc.co.uk/radio4 and follow the links to Inside Health. But please don't e-mail us about the evidence base for garlic in Raynaud's - or in anything else for that matter - we are already looking in to it, and will report back soon.

    Just time to tell you about next week's programme when I will be finding out why underactive thyroids are a particular problem in pregnancy, and one that is often missed, and we answer a listener's concerns about the dangers of electronic cigarettes. Join me then to find out more.

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