Report on Tobacco Harm Reduction by Royal College of Physicians
Sunday, October 07, 2007
Jonathan Foulds, MA, MAppSci, PhD
On Friday (October 5th) the Royal College of Physicians (London) released their latest report on tobacco and health, entitled, “Harm Reduction in Nicotine Addiction: Helping People Who Can’t Quit”. In the preface to the report, Professor John Britton, Chair of the RCP’s Tobacco Advisory Group, stated,
“Harm reduction is a fundamental component of many aspects of medicine and, indeed, everyday life, yet for some reason effective harm reduction principles have not been applied to tobacco smoking. This report makes the case for radical reform of the way nicotine products are regulated and used in society. The ideas we present are controversial, and challenge many current and entrenched views in medicine and public health. They also have the potential to save millions of lives. They deserve serious consideration.”
The 242-page report was written by a group of leading experts on tobacco from the UK, New Zealand, Canada and the United States. It reviews the history of tobacco use, the neurobiology of nicotine addiction, the health risks of various nicotine products and current regulation of nicotine delivery products, before making recommendations on future nicotine product regulation. Among the key conclusions and recommendations are the following:
- Most of the deaths and disease caused by smoking in the near and medium term future will occur in people who are smoking now.
- Current preventive approaches will be ineffective for the millions of smokers who, despite best efforts to persuade and help them to quit, will carry on smoking.
- Harm reduction in smoking can be achieved by providing smokers with safer sources of nicotine that are acceptable and effective nicotine substitutes.
- There is a moral and ethical duty to provide these products to addicted smokers.
- Current systems of regulation of nicotine products inhibit the development of innovative medicinal nicotine substitutes for cigarettes and perpetuate the use of the most dangerous nicotine products (cigarettes). This is unjust, irrational and immoral.
- The unprecedented and unjustifiable market freedoms enjoyed by manufacturers of cigarettes and other smoked tobacco products must end.
- Low nitrosamine smokeless tobacco products may have a positive role to play in a coordinated and regulated harm reduction strategy which maximizes public health benefit and protects against market exploitation.
The report provides numerous examples of the kinds of irrational regulation currently in place around the world and the effects it has on cigarette smoking for health. In the European Union, for example, Swedish snuff (snus) which has health risks around 90% lower than cigarettes, is banned in every country except Sweden, while cigarettes are available everywhere. Why restrict the public’s choice of tobacco products to only the most harmful ones? In the United States (and many other countries), medicinal nicotine products (e.g. nicotine gum) are sold in packs covered in lengthy warnings and contraindications, while cigarette packs have a very small, brief health warning on the side of the pack. The net result is that many smokers mistakenly believe that the medicinal nicotine products are about as harmful as smoking and so are less inclined to use them.
The new Royal College of Physicians report contains a wealth of information about tobacco, nicotine and health, as well as radical new proposals to reduce the number of smoking-caused deaths. The pdf of the report is available online at no cost at:
http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=234
Labels: harm reduction, nicotine addiction cigarette smoking tobacco, nicotine regulation reduction smoking, quit smoking cessation tobacco advice cigarettes, smokeless
7 Comments:
At Tue Oct 09, 08:32:00 AM 2007,
Anonymous said…
Thank you for posting your thoughts, and the link to the RCP report. At this point, I am neither for, or against, harm reduction strategies; although I have some positive experience with incorporating harm reduction strategies, such as methadone, into substance abuse treatment. I agree that thoughtful and courageous discussion is warranted, and know that many discussions are plagued with bias and political agenda.
I wonder, when you say, “Current preventive approaches will be ineffective for the millions of smokers who, despite best efforts to persuade and help them to quit, will carry on smoking,” how are you defining “current preventative approaches”? I am not sure if you are referring to tobacco treatment strategies, tobacco control policies, public health strategies, or all of the above.
The language associated with tobacco treatment is easily misunderstood, and frequently muddled, so I want to be sure I understand your statement.
At Fri Nov 02, 11:27:00 PM 2007,
Jonathan Foulds, MA, MAppSci, PhD said…
Hi Anonymous,
By "current preventive strategies" I was using the phrase loosely to cover all the prevention and treatment strategies we currently have at our disposal and can practically implement. There is no country or state in the world, whether it be New Zealand or California, that has managed to eradicate smoking or even come close, nor is there any sign of it in the next 25 years. World cigarette consumption is actually increasing.
At Wed Dec 26, 10:23:00 PM 2007,
branchouttara said…
I don't proclaim to be a scientist. I agree with much of what you have written. I am completely baffled though. 1.Since smoking has decreased the increase use of anti-depressants and socially defiant behavior has increased.
2. Obesity just as lethal and medically costly has increased even in children.
3. The abundant use of narcotic abuse and development of lethal street drugs has increased.
Nicotine makes one feel good. It does relieve stress.
I don't think smokeless tobacco is the key. All animals are born with the desire for oral gratification. Breast feeding relies on it.
Cigarettes satisfy the oral fixation. It satisfies the need to have something to do with your hands.
Obesity like cigarette smoking satifies the oral fixation and pleasure centers.
So why not eradicate the Junk science of SHS and come up with a nicotine cigarette that is less harmful that can be smoked.
Oral fixation is the key here along with manipulation of the hands.
Stop going for smokeless and develop a safer smoking stick.
Many who don't smoke cigarettes are smoking other things like marijuana, cocaine, methamphetamine.
Again, it all reverts back to the oral fixation.
At Thu Jan 03, 08:17:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Brabchouttara,
I'm not sure I agree with some of your points..
The phrase, "Its an oral fixation" doesn't really explain anything. Sure most animals are programmed to seek rewarding stimuli by mouth - as we all absorb food and water that way to live but that has little relevance to smoking or other addictive drugs. The most addictive way to take heroin is by intravenous injection, but an addict will take it any way s/he can get it. Its based on the drug effects and not the route of delivery.
Similarly in the placebo-controlled trials of the nicotine gum or inhaler all the people were given something to use daily, but it was only the product containing and delivering nicotine that helped people to quit smoking.
But I agree with you that a product that maybe looks and acts like a cigarette, but delivers aerosolized and smokeless nicotine vapor, without combustion, could be a great product.
At Thu Jan 03, 10:51:00 PM 2008,
branchouttara said…
Thanks for you response.
Let's maybe go a little further with the oral fixation. Unlike heroine and other addictive drugs with preferred route IV. The Cigarette is different.
Often, I find that when people view smoking they view it as replacement of the nicotine. There is far more to the act of cigarette smoking than addiction. I know most may find that hard to believe but there is.
If it was purely an addiction to the drug then all things being equal smokeless tobacco would of been readily adapted too. Many who smoke cigarettes do not find the same pleasure out of smokeless tobacco. Yet both if not more nicotine is in smokeless tobacco.
Anti smoking products do not usually work right off the bat if ever actually. It's not the nicotine or the addictive response to the drug.
Cigarettes have different components of satification. One of the relaxing techniques in yoga, lamaze sp? is breathing. Inhaling and exhaling a comforting sensation. achieved in cigarette smoking. Many who smoke marijuana do not smoke cigarettes. and vice versa. The cigarette smoker is not looking for a euphoric high.
I have found that many who have never smoked are not as appaulled at the smell of cigarette smoke as those who have quit. Those who have quit almost have a distinct hate for the smell.
They have had to learn to hate it to stop it. They miss it. Many smoke after meals it seems to relieve some of the bloated feeling.
Those trying to make change in smoking are attempting to erradicate it on a simple addiction theory. Not the approach of what makes the cigarette rewarding.
Again, if it was just addiction then smokeless tobacco and anti smoking drugs would be readily latched onto and we would not be having this conversation.
I find that children are more likely now than ever before to get hooked on prescription drugs. they are conceilable. Therefore, unlike smoking where the public and teachers could visualize defiant behavior they are now still being defiant with more lethal substances.
Most kids will tell you they hate smoking as you are pumping their stomach for the overdose of the medicine cabinet.
At Fri Jan 04, 09:48:00 PM 2008,
Jonathan Foulds, MA, MAppSci, PhD said…
Branchouttara,
There certainly is more to smoking than nicotine...but not much! Or to put it in the words of my former mentor, Professor Michael Russell, "if it wasn't for the nicotine in tobacco, people would be no more inclined to smoke cigarettes than they are to blow bubbles." (I may have slightly misquoted but you get the idea).
To address your point about smokeless tobacco...it has a slight disadvantage in that it can't deliver nicotine quite as quickly as smoke, which can deliver a high concentration to the brain in 10 seconds. Smokeless takes a few minutes at best. But despite that important disadvantage on speed, there are parts of the world where large sections of the population chew tobacco rather than smoke (e.g. women in India). Perhaps the most noteable is Sweden, where more men now use a particular form of smokeless called "snus" than smoke cigarettes. The "Swedish experience" is among the best evidence that it really is the nicotine that people want from tobacco. Smokeless is fairly disgusting stuff, but with a bit of encouragement a large proportion of smokers can switch to it.
On the issue of the "oral fixation"...if thats all it was, then the nicotine inhaler would easily be the best smoking cessation product (in fact a dummy cigarette might be enough), but in fact although the nicotine inhaler helps people quit, it is not any better than the gum or the patch.
So I think we may have to agree to differ in our views of some aspects of smoking. But you are right that people get more out of it than just relief from withdrawal symptoms. There are certain direct effects that some smokers like that are primary effects of nicotine (e.g. appetite suppression, and a small improvement in concentration/alertness).And of course many smokers derive simple satisfaction - almost certainly triggered by the ability of nicotine to release dopamine in the reward center of the brain. But there are now sources of nicotine that can provide these subtle effects without causing lung cancer, emphysema etc. So its definately time to quit smoking.
At Fri Jan 04, 10:17:00 PM 2008,
branchouttara said…
quitting smoking does not alleviate one's risk of contracting lung cancer. I will give you emphysema to a certain respect. Taking into consideration of other factors such as living in orchards, working in Mills or processing plants. Most of those I have known that have died of active lung cancer are former smokers of 10-20 years. In one case 30 years. Recently, I have noted a vast increase in Breast Cancer among woman who have never smoked. They did hold one common denominator that I novicely found and that was premarin. I have also seen a common denominator of two hair dressors both non smokers working in the same shop 1 come down with breast cancer and the other liver cancer. Both non smokers. I believe soley in children not smoking. Like anything else I feel that if you can get them to 18 drug free, alcohol free the battle is pretty much won. Smoking emphasis is so strong that no offense, I believe that researchers have found two things in using smoking as the scape goat. 1. An over abundance of financial contributions from pharmeceutical companies and special agenda groups.
2. They have run into a dead end in putting their finger on what is the real source of cancer development in human beings. Animals are also not protected from Cancer or diabetes. Animals do not partake in cigarette's, alcohol or the like.
The best solution to maintain freedom and satisfy one's natural desire for cigarettes, foods, etc would be to focus more on the cause of cancer and the ability to impede it. Cigarette smoking is a dead end and not the solution.
As smoking has gone down obesity has gone up. With the increase in obesity has come the increase in diabetes even in children. Even though less of the population is smoking the incidence of Child Hood Asthma has not been obliterated.
Do you think sir that we are leaning in the wrong direction and the outcome will be nothing more that targeting and unkindness toward a lifestyle choice.
I believed very much in medicine, non nonmaleficence, the power and wealth in scientific progress.
I have over the last 5 years opened my eyes that when we stop looking for cures and start on preventative measures what we are saying is science has ended and data collection has begun.
I really don't believe that is what this should all be about.
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