Journal of Public Health | Vol. 34, No. 3, pp. 320 321 | doi:10.

1093/pubmed/fds051 | Advance Access Publication 21 June 2012

Guest Editorial
McKee and Raine16 have pointed out, with reference to choices about health, rst choose your philosophy. We believe that the appropriate philosophy in relation to health care is that while the treatment of disease has been delegated to health-care professionals, low-dose aspirin is prophylactic and whether or not to take it is ultimately the responsibility of subjects themselvesjust as non-smoking, dietary choice and regular physical activity are a subjects own choice. The responsibility of health-care practitioners is therefore to ensure that adequate information on risks and benets of all prophylactic measures is made widely available to enable people to make informed decisions about the protection of their own health. As a recent editorial commented: a decision on whether or not a patient should take an aspirin requires a robust discussion of its benets and harms . . . . [and] the elicitation of patient preferences.17 Lenaghan et al.18 has urged that decision-makers at a local and national level should take time and make an effort to obtain informed comment from groups representative of the general public, and should not only listen to but should act on the voice of the public. A Citizens Jury conducted a few years ago under the title: My Health whose responsibility? used low-dose aspirin as an example of a prophylactic medicine.19 The verdicts of 16 jurors, chosen to be representative of the general public, stated that public money should be spent on informing people about the risks and benets of low-dose aspirin, and although at the time of that jury (2006) the available evidence on the reduction of cancer by aspirin was only suggestive, the jurors stated that the evidence on the risks and possible benets of prophylactic drugs should be made available to the public . . . . even before there is agreement amongst doctors (our italics). The Wanless report on Securing good health for the whole population20 stated that health services in the UK are unsustainable in their current form unless members of the public are fully engaged and take responsibility for their own health. The role of prophylactic aspirin, and how it might be handled within health care is being intensely debated in clinical circles and amongst epidemiologists. For

Prophylactic aspirin and public health

Low-dose aspirin prophylaxis is widely promoted for patients who have evidence of vascular disease, together with subjects who have a raised vascular risk score. The use of prophylactic aspirin by healthy subjects is however controversial on the grounds that the number of vascular events likely to be prevented can be close to the number of haemorrhagic episodes likely to be precipitated by the drug.1 A number of large-scale prospective studies have now given evidence that aspirin also reduces cancer incidence. Its use for this purpose is however controversial, again on the basis of the risk of haemorrhage.2 These risk/benet evaluations appear to be based on the assumption that a bleed can be equated with a heart attack, a stroke or a cancer. With regard to both severity and sequelae this can clearly be challenged, and a comment in one of the major overviews of aspirin trials is apposite: . . . the alternative to primary prevention is deferral . . . .. [but] the rst manifestation[s] of disease might be a disabling or fatal event.3 Evidence from an overview of primary vascular randomized trials4 shows that the risk of death from gastrointestinal bleeding in subjects randomized to aspirin (4 per 100 000 subjects per year) is almost identical to that in subjects who had been randomized to placebo (5 per 100 000 per year).5 The report of one of the largest meta-analysis conrms this: . . . there were actually fewer fatal bleeds in participants allocated to aspirin than in the controls (nine vs twenty).6 This absence of a difference in mortality suggests that bleeds caused by aspirin are not the most serious. Furthermore, the long-term follow-up by Rothwell et al.,7 based on 51 randomized trials, shows a marked and signicant decrease over the rst few years in bleeding attributable to aspirin. On the basis of vascular risk alone, recommendations have been made,8 10 and challenged,11 that prophylactic aspirin be considered by subjects over the age of 50 years. For cancer prevention, Rothwell et al.12 recommend aspirin from the age of 45 years. In fact, population surveys show that many older people have made their decision and about one-third in people in Wales,13,14 and rather more in the USA15 state that they take aspirin regularly.

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Peter Elwood, Honorary Professor Marcus Longley, Professor of Applied Health Policy

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# The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

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people generally, the distinction between a medicine such as aspirin and other preventive approaches is arbitraryall are readily available consumer choices, and all carry potential, but uncertain risks and benets. It is time that public health specialists engage with this issue to help people understand the evidence and ensure that members of the general public are equipped to make informed choices on issues of enormous potential to health. Peter Elwood1, Marcus Longley2
1

7 Rothwell PM, Price JF, Fowkes FGR et al. Short-term effects of daily aspirin on cancer incidence, mortality and non-vascular death: analysis of the time course of risks and benets in 51 randomised trials. Lancet 2012; doi:10.1016/s0140-6736(11)61720-0. 8 Elwood P, Morgan G, Brown G et al. Aspirin for all over 50? For. BMJ 2005;330:1440 2. 9 Vandvic PO, Lincoff AM, Gore JM et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis: Amer College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:637S 68S. 10 US Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: US preventive services task force recommendation statement. Ann Intern Med 2009;150:396 404. 11 Baigent C. Aspirin for all over 50? Against. BMJ 2005;330:1442 3. 12 Rothwell PM, Fowkes FGR, Belch JFF et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. Lancet 2011;377:31 41. 13 Elwood P, White J, Fone D et al. Aspirin taking in Caerphilly: a pilot survey. Br J Cardiol 2011;18:238 40. 14 Elwood P, Morgan G, White J et al. Aspirin taking in a South Wales County. Br J Cardiol 2011;18:238 40. 15 Ajani UA, Ford ES, Greenland KJ. Aspirin use among US adults: Behavioural Risk Factor Surveillance System. Am J Prev Med 2006;30:74 7. 16 McKee M, Raine R. Choosing health? First choose your philosophy. Lancet 2005;365:369 71. 17 Kent DM, Shah ND. Personalising evidence-based primary prevention with aspirin. Individualised risks and patient preference. Circ Cardiovasc Qual Outcomes 2011;4:260 2. 18 Lenaghan J, New B, Mitchell E. Setting priorities: is there a role for Citizens juries? BMJ 1996;312:1591 3. 19 Elwood PC, Longley M. My healthwhose responsibility: a jury decides. J Epidem Comm Health 2010;64:761 4. 20 Wanless D, Treasury HM. Securing good health for the whole population. HM 7 Treasury, 2004 ISBN: 0-947819-98-3.
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Department of Primary Care and Public Health, Cardiff University, Cardiff, UK E-mail: elwoodpc@cf.ac.uk 2 Welsh Institute for Health and Social Care, University of Glamorgan, Pontypridd, UK

References
1 Drugs and Therapeutic Bulletin. Aspirin for primary prevention of cardiovascular disease? 2009;47:122 5. 2 Kurth T. Aspirin and cancer prevention. BMJ 2012;344:e2480. 3 Antithrombotic Trialists Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373:1849 60. 4 Guise J-M, Mahon SM, Aicken M et al. Aspirin for the prevention of cardiovascular events: a summary of the evidence. Ann Intern Med 2002;136:161 72. 5 Morgan G. Aspirin for the prevention of vascular events. Public Health 2009;123:787 818. 6 Antithrombotic Trialists Collaboration. Collective meta-analysis of randomised trial of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. BMJ 2002;324:71 86.