From the Financial Times:
Last gaspers
By Richard Tomkins
Published: January 4 2008 21:30 | Last updated: January 4 2008 21:30
For more than a century, the cigarette has exercised its seductive power over human beings. Its allure lies in its mutability; in its power to become whatever people want it to be. To the low in spirits, it is a pick-me-up, yet it calms down the harassed. To the lonely, it is a companion, yet it is also convivial between friends. It is a reward when things go well, yet a consolation when things go badly. It is a crutch for the nervous, yet it is flaunted by the bold.
At its most mundane, the smoking of a cigarette may merely satisfy a craving, relieve the boredom or punctuate the passing of the day. But, at least until recently, it was often much more. In the movies, it was portrayed as glamorous, sexy and cool. For artists and intellectuals, it was an aid to creativity and thought. For the man facing the firing squad, it was his solace at the moment of death.
In Britain, however, the cigarette no longer beguiles as it did. Exposed as addictive and deadly, killing half of its long-term users, it has been condemned by the public health community, rejected by a growing majority of adults and, step by step, driven towards the margins of society. No longer are people urged to “Come to Marlboro Country” by 48-sheet billboards or full-page advertisements in glossy magazines. It is rare, and even slightly shocking, for public figures to be seen in the media with a cigarette in mouth or hand.
Today, six months after England followed the rest of the UK in introducing a widespread smoking ban, the cigarette seems a throwback to a repellent and unhealthy past. There is almost no enclosed public area where smoking is allowed. If one could only avoid the smoker’s last refuges – his home and, paradoxically, the fresh air – it would be almost possible to imagine what life would be like if cigarettes ceased to exist.
It is a tantalising thought. As recently as the 1980s, smoking was still the social norm. You could light up almost anywhere – in cinemas, in hospitals and even on Underground trains. If attitudes have changed so much in such a short period, are we now within reach of a future in which smoking is finally eradicated?
Cigarette smoking peaked in industrialised nations around the middle of the 20th century. In Britain, 82 per cent of men smoked tobacco in 1948, mostly in the form of cigarettes, and many more women were starting to smoke, too. Then, in the 1950s, the British epidemiologist Richard Doll (later Sir Richard) demonstrated the link between smoking and lung cancer. Cigarette smoking started to decline, and by the 1970s and 1980s, as the risks of smoking became ever clearer, smokers were quitting in droves.
Britain, along with other western countries, is now in the late stages of the typical smoking epidemic. In the early stages – where the developing world is now – increasing numbers of men take up smoking, then women join in, and after a lag deaths from smoking-related diseases start to climb. In the later stages, men start quitting, then women join in, and after a lag deaths from smoking start to decline.
The first puff of smoke
The cigarette smoking epidemic began one day in 1880 when an American named James Bonsack, just 21 at the time, unveiled an extraordinary invention: the cigarette-rolling machine. Until then, tobacco had either been taken as snuff, rolled up into cigars, smoked in pipes and, in the US particularly, chewed; but the only manufactured cigarettes on the market were hand-rolled in factories by so-called cigarette girls, as featured in Bizet’s opera Carmen which premiered in 1875.
The Bonsack machine transformed the economics of cigarette-making. A skilled girl could roll four cigarettes a minute, but the Bonsack machine could turn out at least 200 in the same time – and go on turning them out, hour after hour, without the need for rest or refreshment. Mechanisation not only made manufactured cigarettes much cheaper, but brought them into the era of mass-produced, branded packaged goods, heavily advertised and aggressively marketed by companies seeking to maximise the economies of scale. The time was right for cigarettes, too. As industrialisation took hold and people moved from the countryside to the cities, the cigarette seemed better suited to the faster pace of life than the old ways of consuming tobacco did. Cigarettes were quicker and more convenient to smoke than cigars or pipes, which seemed to belong to a more leisurely age, and were much less disagreeable in crowded cities than chewing, with the spitting that inevitably accompanied it.
The good news in Britain is that the proportion of men who smoke has fallen to 25 per cent and the proportion of women has fallen to 23 per cent, giving an overall level of 24 per cent. At this rate, extrapolating a straight line from 1948 to the present, the last male would quit smoking in 2033.
The bad news is that there is no longer any downward trend to extrapolate. According to the Office for National Statistics, the overall smoking rate bottomed out at its present level in 2001 and has flatlined ever since. In fact, in absolute terms, the number of smokers in Britain has gone up since 2001, from 9.5 million to 9.9 million, because of population growth.
To be fair, the statistics for present-day smoking rates were collected before England’s recent smoking ban came into effect. Although the ban was ostensibly aimed at protecting people from second-hand smoke, it may also have helped “de-normalise” smoking, encouraging people to quit.
Even so: supposing the ban takes the smoking rate down to, say, 20 per cent. What then? All anti-smoking interventions known to be effective are now in place. Public information campaigns have made the dangers of smoking clear beyond doubt; the advertising and marketing of all tobacco products has been banned; all cigarette packs carry prominent health warnings; smokers have free access to stop-smoking programmes; Britain’s cigarette taxes are among the highest in the world; and now, there are almost no enclosed public spaces left where smoking is allowed. Short of prohibition, not widely seen as an option, there is little left for the government to do, apart from tinker with existing measures.
It is not as though other countries are doing much better. True, some report extremely low smoking rates among women – but only because these are countries where female smoking is not tolerated. If male smoking rates are compared, there is almost no country with a rate below 20 per cent. Even California, aggressively anti-tobacco since the 1980s and widely regarded as the no-smoking capital of the world, had a male smoking rate of 19.2 per cent in 2005.
There is, however, one country that’s doing better. This is Sweden, where only 13 per cent of males were daily smokers in 2005. The reason is that many Swedish men get their nicotine fix not from cigarettes but from a Scandinavian product called snus (rhymes with loose), a moist tobacco contained in a small sachet that is placed under the top lip. Because snus does not cause spitting, it is cleaner and more socially acceptable than traditional chewing tobacco.
The point about snus is that, although controversial even in Sweden, it appears to be much safer to use than cigarettes. Nicotine, after all, may be powerfully addictive, but it is not particularly harmful; it is the smoke produced when tobacco is burned that carries the carcinogens. Because the Swedes have found a way of getting their nicotine without the smoke, they have the lowest lung cancer rate in Europe. Unlike smoking, snus also appears to carry little or no risk of mouth cancer.
And so, the public health community confronts a dilemma. If the half-century decline in smoking has stalled, what should it do? Carry on regardless, campaigning against tobacco use in all its forms even though a final victory, if attainable at all, may lie in the distant future? Or should it shift tactics, accepting that many people will never quit nicotine and looking for a safer way of giving them what they want?
Like most middle-class professionals, Professor Martin Jarvis, a psychologist specialising in tobacco dependence at University College London, is a non-smoker. It was not always so; he remembers well the day he quit. “It was April 1 1969, the day I got married,” he says. “My wife and I gave up together on our wedding day.”
These days, smoking rates among professionals of both sexes are down to about 15 per cent. For them, and for the middle classes in general, it may seem smoking is on the way out. The disturbing truth is, however, that among the poorest groups in society, the smoking rate is still about 60 per cent. “And if you look at particular sub-groups, it’s higher,” Jarvis says. “In some psychiatric patients it’s 70 per cent or more, among homeless people living rough it’s over 80 per cent, and among prisoners in jail it’s over 80 per cent. In a way, that’s the strongest indicator that smoking isn’t going to go away, because the prevalence in those deprived groups has really stayed pretty much the same over the past 30 years.”
Research shows that deprived people want to give up just as much as those in more affluent groups, Jarvis says, but, for a mixture of reasons, they find it harder. They grow up and live among fellow smokers; they are more nicotine-dependent because they are heavier smokers and draw more deeply on each cigarette; and poverty may be burden enough without taking on the strain of withdrawal.
As Jarvis notes, the nicotine that these and other addicts crave is not the thing that is killing them; it is the delivery device – something that has taken many forms over the centuries. In Elizabethan times, it was the clay pipe, then it was snuff, then cigars, cheroots and chewing tobacco. “It’s only the 20th century that gave rise to the cigarette-smoking epidemic, and it may be that what’s more likely than nicotine use withering on the vine and disappearing is that the form of nicotine used by society changes again, to something less toxic than the cigarette and something less likely to kill you.”
The tobacco industry, more than just interested in the cigarette’s future, is already investigating the possibilities. At British American Tobacco’s research and development laboratories in Southampton, David O’Reilly, head of harm reduction science, describes how the company is exploring two different types of product: one, a safer cigarette, and the other, snus.
With the safer cigarette, O’Reilly says, it is already possible to develop products that reduce the consumer’s exposure to toxicants, but the problem is what to do next. “You can’t just put it on the market and wait 30 years to see whether people who have used it have lower levels of lung cancer or heart disease or emphysema.” So, using new developments in biological science, British American Tobacco (BAT) is trying to devise a system of tests and trials that will reliably predict whether a product reduces the risk of smoking-related diseases before it is launched. “We’re probably five to 10 years away from being able to do that, realistically,” O’Reilly says. “But that’s where most of our R&D effort is going.”
With snus, in contrast, which has a long history and regained popularity in the 1970s, “the science is all done, effectively. There’s very good evidence that the product is somewhere between 90 and 98 per cent safer than a cigarette.” Here, the challenge is a consumer challenge: finding out if smokers are prepared to make the leap from cigarettes to a different kind of nicotine experience, with different rituals and cues and a less intense, but longer-lasting, effect.
To that end, BAT is already test marketing snus extensively in South Africa under its Lucky Strike and Peter Stuyvesant brands and has just started test marketing it in Canada under its du Maurier label. But there will be no test marketing in Britain – for the simple reason that snus is banned throughout the EU by European law, except in Sweden, where it has an exemption.
The ban on snus points to an anomaly. As the law stands, tobacco companies are free to sell nicotine to the public even though the cigarettes containing it are known to be lethal. Yet it is illegal to sell alternative nicotine products without a licence even if they are known to be safe.
True, there are patches and chewing gums, nowadays sold over the counter as well as prescribed. However, these are strictly regulated medicinal products designed solely for short-term use by people trying to quit. They do not deliver a large or fast enough “hit” to satisfy regular smokers.
Now, in what could turn out to be a pivotal moment in the history of the cigarette, many in the tobacco-control community are calling for this anomaly to be fixed. In October last year, the Royal College of Physicians published a 256-page report making the case for safer nicotine products to be made available to the severely addicted. Even hardline anti-smoking groups such as Action on Smoking and Health argue that new nicotine products should be introduced to help the millions of cigarette smokers who will simply never give up.
“ASH is not fundamentalist about nicotine,” says Deborah Arnott, director of the pressure group. “Nicotine isn’t harmful to the body at the level taken by addicts, nor does it have the socially harmful effects of drugs like alcohol and crack cocaine. In fact, it could be considered as similar to caffeine if it weren’t for the delivery device – the cigarette – which kills half all long-term smokers. We support a pragmatic harm-reduction approach, making faster-acting, medicinal nicotine products available to heavy smokers who can’t quit, and encouraging them to switch.”
However, it is an idea that divides the public health community. At one extreme, some believe all drug use is wrong and it would be immoral to condone nicotine dependency. Others would accept any nicotine product in principle, provided it substantially reduced the harm to smokers. Between them are those who would accept medicinal nicotine products but are deeply opposed to anything coming out of the tobacco industry, such as snus.
Suspicion of the tobacco industry runs deep in the public health community – for good reason. Internal documents now in the public domain show how, over the decades, the industry concealed its knowledge about nicotine addiction and the dangers of smoking. There was also the so-called “lights” affair, when tobacco companies launched low-tar versions of their popular brands that were supposedly safer but which later turned out to be almost as dangerous as conventional cigarettes because smokers puffed harder on them to get the same effect.
In Sweden, Dr Goran Boëthius, chairman of the non-profit Doctors Against Tobacco, says it is clear why tobacco companies are promoting snus: “It is the latest trick to keep up or increase nicotine dependence – that is, to stay in business.” Clean nicotine is better than dirty nicotine, he says, the cigarette being the dirtiest nicotine product of all. “But snus is also dirty, containing maybe 2,000 chemicals instead of the 4,000 in cigarette smoke.”
Dr Bobbie Jacobson, director of the London Health Observatory, a public sector health monitoring body, says she thinks most people in the public health community would accept the use of nicotine products as part of a harm reduction strategy but would draw the line at anything based on tobacco. “All forms of tobacco have got adverse health consequences and no government in its right mind should be supporting the use of a product that is hazardous to health,” she says.
At present, there is nowhere in the world where nicotine addicts are offered safer substitutes for cigarettes on a continuing, long-term basis. Interestingly, however, the British government has signalled that it is ready to discuss the options. In its Cancer Reform Strategy, unveiled last month, the Department of Health said it would consult interested parties on measures “to reduce the significant harm to health caused by smoking for those who are addicted to nicotine and not able to quit altogether”.
The obstacles to the introduction of reduced-harm nicotine products are immense. It could be seen as setting a precedent for the legalisation of recreational drugs. There would be worries, too, about encouraging nicotine addiction. As the British epidemiologist Sir Richard Peto, a former colleague of Sir Richard Doll, puts it: “It’s obviously dangerous playing with maintaining an addiction to something that, in its most commonly used form, kills half of those who use it.” Conceivably, children who would never have smoked could get hooked on alternative nicotine products and move on to cigarettes later.
On a more practical note, there is the question of who would manufacture these products. Any company that succeeded in devising a satisfying substitute for the cigarette would probably be accused of feeding off people’s addiction and could end up being demonised in much the same way as the tobacco companies.
“Our products are there for health reasons and there’s no real health reason for people to be addicted to nicotine,” says a senior executive of one of the biggest pharmaceutical companies. “So if we were effectively making money out of people’s addiction, out of supporting people’s addiction – well, I think it’s an area we just wouldn’t want to get into.”
Perhaps small manufacturers might enter the market. In 2005 a German company called Nautilus GmbH Laboratoriumsbedarf announced it was launching a nicotine beer called NicoShot, though it has yet to obtain regulatory clearance; earlier, nicotine lollipops proliferated in the US before the Food and Drug Administration banned them. Otherwise, the most obvious market entrant is probably the one the public health community would least like to see – the tobacco industry itself.
“If non-tobacco nicotine for pleasure takes off, it’s definitely something we would explore, because we would see that as a natural fit for our business,” says Michael Prideaux, BAT’s corporate and regulatory affairs director. “It would be a tussle between us and the pharmaceutical companies” – that is, if the pharmaceutical companies even wanted to play.
At the Royal College of Physicians, Professor John Britton, whose tobacco advisory group produced that hefty nicotine report, acknowledges the difficulties. However, he prefers to focus on the opportunities. He rehearses the figures: since half of all smokers die early if they do not give up, and Britain has about 10 million smokers, that means 5 million Britons alive today will die from smoking unless they quit.
“If those people can be persuaded or encouraged to use a safer product instead, and the harmful product is made less and less accessible and affordable to them, the impact on public health will be massive,” he says – possibly the biggest advance since the introduction of public sanitation in the 19th century.
“And if we end up with a society where 35 per cent of people use a safe nicotine product every day, so what?”
Copyright The Financial Times Limited 2008
Last gaspers
By Richard Tomkins
Published: January 4 2008 21:30 | Last updated: January 4 2008 21:30
For more than a century, the cigarette has exercised its seductive power over human beings. Its allure lies in its mutability; in its power to become whatever people want it to be. To the low in spirits, it is a pick-me-up, yet it calms down the harassed. To the lonely, it is a companion, yet it is also convivial between friends. It is a reward when things go well, yet a consolation when things go badly. It is a crutch for the nervous, yet it is flaunted by the bold.
At its most mundane, the smoking of a cigarette may merely satisfy a craving, relieve the boredom or punctuate the passing of the day. But, at least until recently, it was often much more. In the movies, it was portrayed as glamorous, sexy and cool. For artists and intellectuals, it was an aid to creativity and thought. For the man facing the firing squad, it was his solace at the moment of death.
In Britain, however, the cigarette no longer beguiles as it did. Exposed as addictive and deadly, killing half of its long-term users, it has been condemned by the public health community, rejected by a growing majority of adults and, step by step, driven towards the margins of society. No longer are people urged to “Come to Marlboro Country” by 48-sheet billboards or full-page advertisements in glossy magazines. It is rare, and even slightly shocking, for public figures to be seen in the media with a cigarette in mouth or hand.
Today, six months after England followed the rest of the UK in introducing a widespread smoking ban, the cigarette seems a throwback to a repellent and unhealthy past. There is almost no enclosed public area where smoking is allowed. If one could only avoid the smoker’s last refuges – his home and, paradoxically, the fresh air – it would be almost possible to imagine what life would be like if cigarettes ceased to exist.
It is a tantalising thought. As recently as the 1980s, smoking was still the social norm. You could light up almost anywhere – in cinemas, in hospitals and even on Underground trains. If attitudes have changed so much in such a short period, are we now within reach of a future in which smoking is finally eradicated?
Cigarette smoking peaked in industrialised nations around the middle of the 20th century. In Britain, 82 per cent of men smoked tobacco in 1948, mostly in the form of cigarettes, and many more women were starting to smoke, too. Then, in the 1950s, the British epidemiologist Richard Doll (later Sir Richard) demonstrated the link between smoking and lung cancer. Cigarette smoking started to decline, and by the 1970s and 1980s, as the risks of smoking became ever clearer, smokers were quitting in droves.
Britain, along with other western countries, is now in the late stages of the typical smoking epidemic. In the early stages – where the developing world is now – increasing numbers of men take up smoking, then women join in, and after a lag deaths from smoking-related diseases start to climb. In the later stages, men start quitting, then women join in, and after a lag deaths from smoking start to decline.
The first puff of smoke
The cigarette smoking epidemic began one day in 1880 when an American named James Bonsack, just 21 at the time, unveiled an extraordinary invention: the cigarette-rolling machine. Until then, tobacco had either been taken as snuff, rolled up into cigars, smoked in pipes and, in the US particularly, chewed; but the only manufactured cigarettes on the market were hand-rolled in factories by so-called cigarette girls, as featured in Bizet’s opera Carmen which premiered in 1875.
The Bonsack machine transformed the economics of cigarette-making. A skilled girl could roll four cigarettes a minute, but the Bonsack machine could turn out at least 200 in the same time – and go on turning them out, hour after hour, without the need for rest or refreshment. Mechanisation not only made manufactured cigarettes much cheaper, but brought them into the era of mass-produced, branded packaged goods, heavily advertised and aggressively marketed by companies seeking to maximise the economies of scale. The time was right for cigarettes, too. As industrialisation took hold and people moved from the countryside to the cities, the cigarette seemed better suited to the faster pace of life than the old ways of consuming tobacco did. Cigarettes were quicker and more convenient to smoke than cigars or pipes, which seemed to belong to a more leisurely age, and were much less disagreeable in crowded cities than chewing, with the spitting that inevitably accompanied it.
The good news in Britain is that the proportion of men who smoke has fallen to 25 per cent and the proportion of women has fallen to 23 per cent, giving an overall level of 24 per cent. At this rate, extrapolating a straight line from 1948 to the present, the last male would quit smoking in 2033.
The bad news is that there is no longer any downward trend to extrapolate. According to the Office for National Statistics, the overall smoking rate bottomed out at its present level in 2001 and has flatlined ever since. In fact, in absolute terms, the number of smokers in Britain has gone up since 2001, from 9.5 million to 9.9 million, because of population growth.
To be fair, the statistics for present-day smoking rates were collected before England’s recent smoking ban came into effect. Although the ban was ostensibly aimed at protecting people from second-hand smoke, it may also have helped “de-normalise” smoking, encouraging people to quit.
Even so: supposing the ban takes the smoking rate down to, say, 20 per cent. What then? All anti-smoking interventions known to be effective are now in place. Public information campaigns have made the dangers of smoking clear beyond doubt; the advertising and marketing of all tobacco products has been banned; all cigarette packs carry prominent health warnings; smokers have free access to stop-smoking programmes; Britain’s cigarette taxes are among the highest in the world; and now, there are almost no enclosed public spaces left where smoking is allowed. Short of prohibition, not widely seen as an option, there is little left for the government to do, apart from tinker with existing measures.
It is not as though other countries are doing much better. True, some report extremely low smoking rates among women – but only because these are countries where female smoking is not tolerated. If male smoking rates are compared, there is almost no country with a rate below 20 per cent. Even California, aggressively anti-tobacco since the 1980s and widely regarded as the no-smoking capital of the world, had a male smoking rate of 19.2 per cent in 2005.
There is, however, one country that’s doing better. This is Sweden, where only 13 per cent of males were daily smokers in 2005. The reason is that many Swedish men get their nicotine fix not from cigarettes but from a Scandinavian product called snus (rhymes with loose), a moist tobacco contained in a small sachet that is placed under the top lip. Because snus does not cause spitting, it is cleaner and more socially acceptable than traditional chewing tobacco.
The point about snus is that, although controversial even in Sweden, it appears to be much safer to use than cigarettes. Nicotine, after all, may be powerfully addictive, but it is not particularly harmful; it is the smoke produced when tobacco is burned that carries the carcinogens. Because the Swedes have found a way of getting their nicotine without the smoke, they have the lowest lung cancer rate in Europe. Unlike smoking, snus also appears to carry little or no risk of mouth cancer.
And so, the public health community confronts a dilemma. If the half-century decline in smoking has stalled, what should it do? Carry on regardless, campaigning against tobacco use in all its forms even though a final victory, if attainable at all, may lie in the distant future? Or should it shift tactics, accepting that many people will never quit nicotine and looking for a safer way of giving them what they want?
Like most middle-class professionals, Professor Martin Jarvis, a psychologist specialising in tobacco dependence at University College London, is a non-smoker. It was not always so; he remembers well the day he quit. “It was April 1 1969, the day I got married,” he says. “My wife and I gave up together on our wedding day.”
These days, smoking rates among professionals of both sexes are down to about 15 per cent. For them, and for the middle classes in general, it may seem smoking is on the way out. The disturbing truth is, however, that among the poorest groups in society, the smoking rate is still about 60 per cent. “And if you look at particular sub-groups, it’s higher,” Jarvis says. “In some psychiatric patients it’s 70 per cent or more, among homeless people living rough it’s over 80 per cent, and among prisoners in jail it’s over 80 per cent. In a way, that’s the strongest indicator that smoking isn’t going to go away, because the prevalence in those deprived groups has really stayed pretty much the same over the past 30 years.”
Research shows that deprived people want to give up just as much as those in more affluent groups, Jarvis says, but, for a mixture of reasons, they find it harder. They grow up and live among fellow smokers; they are more nicotine-dependent because they are heavier smokers and draw more deeply on each cigarette; and poverty may be burden enough without taking on the strain of withdrawal.
As Jarvis notes, the nicotine that these and other addicts crave is not the thing that is killing them; it is the delivery device – something that has taken many forms over the centuries. In Elizabethan times, it was the clay pipe, then it was snuff, then cigars, cheroots and chewing tobacco. “It’s only the 20th century that gave rise to the cigarette-smoking epidemic, and it may be that what’s more likely than nicotine use withering on the vine and disappearing is that the form of nicotine used by society changes again, to something less toxic than the cigarette and something less likely to kill you.”
The tobacco industry, more than just interested in the cigarette’s future, is already investigating the possibilities. At British American Tobacco’s research and development laboratories in Southampton, David O’Reilly, head of harm reduction science, describes how the company is exploring two different types of product: one, a safer cigarette, and the other, snus.
With the safer cigarette, O’Reilly says, it is already possible to develop products that reduce the consumer’s exposure to toxicants, but the problem is what to do next. “You can’t just put it on the market and wait 30 years to see whether people who have used it have lower levels of lung cancer or heart disease or emphysema.” So, using new developments in biological science, British American Tobacco (BAT) is trying to devise a system of tests and trials that will reliably predict whether a product reduces the risk of smoking-related diseases before it is launched. “We’re probably five to 10 years away from being able to do that, realistically,” O’Reilly says. “But that’s where most of our R&D effort is going.”
With snus, in contrast, which has a long history and regained popularity in the 1970s, “the science is all done, effectively. There’s very good evidence that the product is somewhere between 90 and 98 per cent safer than a cigarette.” Here, the challenge is a consumer challenge: finding out if smokers are prepared to make the leap from cigarettes to a different kind of nicotine experience, with different rituals and cues and a less intense, but longer-lasting, effect.
To that end, BAT is already test marketing snus extensively in South Africa under its Lucky Strike and Peter Stuyvesant brands and has just started test marketing it in Canada under its du Maurier label. But there will be no test marketing in Britain – for the simple reason that snus is banned throughout the EU by European law, except in Sweden, where it has an exemption.
The ban on snus points to an anomaly. As the law stands, tobacco companies are free to sell nicotine to the public even though the cigarettes containing it are known to be lethal. Yet it is illegal to sell alternative nicotine products without a licence even if they are known to be safe.
True, there are patches and chewing gums, nowadays sold over the counter as well as prescribed. However, these are strictly regulated medicinal products designed solely for short-term use by people trying to quit. They do not deliver a large or fast enough “hit” to satisfy regular smokers.
Now, in what could turn out to be a pivotal moment in the history of the cigarette, many in the tobacco-control community are calling for this anomaly to be fixed. In October last year, the Royal College of Physicians published a 256-page report making the case for safer nicotine products to be made available to the severely addicted. Even hardline anti-smoking groups such as Action on Smoking and Health argue that new nicotine products should be introduced to help the millions of cigarette smokers who will simply never give up.
“ASH is not fundamentalist about nicotine,” says Deborah Arnott, director of the pressure group. “Nicotine isn’t harmful to the body at the level taken by addicts, nor does it have the socially harmful effects of drugs like alcohol and crack cocaine. In fact, it could be considered as similar to caffeine if it weren’t for the delivery device – the cigarette – which kills half all long-term smokers. We support a pragmatic harm-reduction approach, making faster-acting, medicinal nicotine products available to heavy smokers who can’t quit, and encouraging them to switch.”
However, it is an idea that divides the public health community. At one extreme, some believe all drug use is wrong and it would be immoral to condone nicotine dependency. Others would accept any nicotine product in principle, provided it substantially reduced the harm to smokers. Between them are those who would accept medicinal nicotine products but are deeply opposed to anything coming out of the tobacco industry, such as snus.
Suspicion of the tobacco industry runs deep in the public health community – for good reason. Internal documents now in the public domain show how, over the decades, the industry concealed its knowledge about nicotine addiction and the dangers of smoking. There was also the so-called “lights” affair, when tobacco companies launched low-tar versions of their popular brands that were supposedly safer but which later turned out to be almost as dangerous as conventional cigarettes because smokers puffed harder on them to get the same effect.
In Sweden, Dr Goran Boëthius, chairman of the non-profit Doctors Against Tobacco, says it is clear why tobacco companies are promoting snus: “It is the latest trick to keep up or increase nicotine dependence – that is, to stay in business.” Clean nicotine is better than dirty nicotine, he says, the cigarette being the dirtiest nicotine product of all. “But snus is also dirty, containing maybe 2,000 chemicals instead of the 4,000 in cigarette smoke.”
Dr Bobbie Jacobson, director of the London Health Observatory, a public sector health monitoring body, says she thinks most people in the public health community would accept the use of nicotine products as part of a harm reduction strategy but would draw the line at anything based on tobacco. “All forms of tobacco have got adverse health consequences and no government in its right mind should be supporting the use of a product that is hazardous to health,” she says.
At present, there is nowhere in the world where nicotine addicts are offered safer substitutes for cigarettes on a continuing, long-term basis. Interestingly, however, the British government has signalled that it is ready to discuss the options. In its Cancer Reform Strategy, unveiled last month, the Department of Health said it would consult interested parties on measures “to reduce the significant harm to health caused by smoking for those who are addicted to nicotine and not able to quit altogether”.
The obstacles to the introduction of reduced-harm nicotine products are immense. It could be seen as setting a precedent for the legalisation of recreational drugs. There would be worries, too, about encouraging nicotine addiction. As the British epidemiologist Sir Richard Peto, a former colleague of Sir Richard Doll, puts it: “It’s obviously dangerous playing with maintaining an addiction to something that, in its most commonly used form, kills half of those who use it.” Conceivably, children who would never have smoked could get hooked on alternative nicotine products and move on to cigarettes later.
On a more practical note, there is the question of who would manufacture these products. Any company that succeeded in devising a satisfying substitute for the cigarette would probably be accused of feeding off people’s addiction and could end up being demonised in much the same way as the tobacco companies.
“Our products are there for health reasons and there’s no real health reason for people to be addicted to nicotine,” says a senior executive of one of the biggest pharmaceutical companies. “So if we were effectively making money out of people’s addiction, out of supporting people’s addiction – well, I think it’s an area we just wouldn’t want to get into.”
Perhaps small manufacturers might enter the market. In 2005 a German company called Nautilus GmbH Laboratoriumsbedarf announced it was launching a nicotine beer called NicoShot, though it has yet to obtain regulatory clearance; earlier, nicotine lollipops proliferated in the US before the Food and Drug Administration banned them. Otherwise, the most obvious market entrant is probably the one the public health community would least like to see – the tobacco industry itself.
“If non-tobacco nicotine for pleasure takes off, it’s definitely something we would explore, because we would see that as a natural fit for our business,” says Michael Prideaux, BAT’s corporate and regulatory affairs director. “It would be a tussle between us and the pharmaceutical companies” – that is, if the pharmaceutical companies even wanted to play.
At the Royal College of Physicians, Professor John Britton, whose tobacco advisory group produced that hefty nicotine report, acknowledges the difficulties. However, he prefers to focus on the opportunities. He rehearses the figures: since half of all smokers die early if they do not give up, and Britain has about 10 million smokers, that means 5 million Britons alive today will die from smoking unless they quit.
“If those people can be persuaded or encouraged to use a safer product instead, and the harmful product is made less and less accessible and affordable to them, the impact on public health will be massive,” he says – possibly the biggest advance since the introduction of public sanitation in the 19th century.
“And if we end up with a society where 35 per cent of people use a safe nicotine product every day, so what?”
Copyright The Financial Times Limited 2008
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