Further evidence that the wealthier are healthier: negative life events and asthma-specific quality of life.

arm have an annual x ray or nothing other than simple follow-up. The contamination rate for the control arm (ie, having a sneak chest radiograph or even a privately paid computed tomogra-phy) is not known, although this reached in excess of 50% in the chest radiograph versus nothing randomised controlled trial led by the Mayo Clinic in the 1950s. Into this area of uncertainty comes a most interesting study with perhaps an intuitively obvious result from Silvestri et al in this month's issue of Thorax (see page 126). 12 They carried out a telephone questionnaire on a nationwide sample of Americans aged >40 years, identified by a random dialling telephone system. From 21 000 households contacted, 2001 individuals were prepared to answer structured questions from a trained interviewer. What transpired was that smokers in the survey were significantly more likely than non-smokers to be male, non-white, less well educated and to report poorer health status or history of cancer, and also (in the US system) to be less able to identify a usual source of healthcare. When contrasting the attitude to screening for risk of disease, the current smokers were less likely than the non-smokers to believe that early detection would result in a good chance of survival. The smokers were also less likely to consider undergoing a computed tomo-graphy for screening for lung cancer, and fewer current smokers believed that the risk of lung cancer or the accuracy of the test was an important factor in deciding whether to enter a screening programme. Even worse, only half of the current smokers would have chosen to opt for surgical removal of a screen-diagnosed cancer. The authors of the paper are correct to conclude that there remain substantial obstacles to the implementation of a mass screening programme for lung cancer. Many of the problems have been outlined above, without mentioning the huge effect the organisation of such a programme would have on resource, equipment , radiographers, radiologists, surgeons and, not least, the funders. There is even a debate ongoing on the best design for such a programme. Also, with the rapidly improving technology around sophisticated pulmonary imaging, it is hard to see how a 5-year study can be set up without the means to incorporate newer imaging computer programs and other refinements as the study progresses. What about the role of positron emission tomography which is regarded as more sensitive and …