LETTER
Smoking while Wearing a Nicotine Patch
Murray A. Mittleman
15 March 1995 | Volume 122 Issue 6 | Pages 476-477
TO THE EDITOR:
In a recent letter, Warner and Little [1] reported a case of myocardial infarction occurring in a patient wearing a nicotine patch. They concluded that "smoking. combined with nicotine patch use may trigger myocardial infarction." In response to this letter, Kafka [2] wrote that "the problem with this patient was not that he was wearing a nicotine patch but rather that he was smoking."
These letters raise several important points about clinical observation, interpretation of associations, and causation in individual cases. First, new observations by astute clinicians alert the medical community to associations between exposure and disease onset. Second, these associations must be examined to determine whether the exposure precedes the outcome more often than would be expected because of chance; that is, observation of the case-exposure relation without control data is by necessity inconclusive. Third, even after an association has been established and is believed to be causal, causation cannot be certain in any specific case when the exposure of interest is not a "necessary cause" [3] for disease onset.
1. Warner JG, Little WC. Myocardial infarction in a patient who smoked while wearing a nicotine patch (Letter). Ann Intern Med. 1994; 120:695.
2. Kafka HP. Heart attacks, smoking, and the nicotine patch (Letter). Ann Intern Med. 1994; 121:389.
3. Rothman KJ. Modern Epidemiology. Boston: Little, Brown; 1986.
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•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
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