Select Committee on Health Second Report


III NICOTINE ADDICTION AND REGULATION

182. The author of a discussion paper, Smoking, Nicotine and Society, produced for Pharmacia and Upjohn, describes the way in which nicotine works:

    "Nicotine works at sites in the brain which are normally activated by the neurotransmitter ... acetylcholine. This in turn alters the levels of other natural neurotransmitters, including nor-adrenaline, dopamine and serotonin. They are involved in the functioning of the brain, and mood. Low levels of nor-adrenaline are, for example, associated with depression.

    Taking nicotine has a range of potential effects. In people who have not developed dependence the dominant response may be one of pleasure. This is probably associated with increases in the dopamine levels in a part of the brain known as the limbic reward system. But those who have adjusted to nicotine (by, for example, changing the number of receptors for key neurotransmitters) may need to keep taking it simply to avoid distress which occurs when levels drop too low."[320]

183. The RCP in their recent report on nicotine addiction in Britain commented: "the presence of nicotine is necessary but not sufficient. Tobacco smoke inhalation is the most highly optimised vehicle for nicotine administration because absorption through the lungs delivers nicotine to the brain rapidly and intensively".[321] The papers disclosed in the Minnesota litigation demonstrate that many tobacco companies have long understood that nicotine addiction lies at the heart of the reason why people smoke. According to the Faculty of Public Health Medicine, tobacco companies know that "cigarettes would not remain viable products without nicotine",[322] and that tobacco smoking is the most efficient way of satisfying this addiction. The Pharmacia and Upjohn paper explained that this form of drug delivery "allows the smoker to experience and control immediate rewards, and is highly addictive". The author went on to suggest "in the same way that 'crack' cocaine is much more dependence inducing than cocaine taken via, say, coca leaf tea, nicotine in inhaled smoke is more addictive than nicotine taken in other ways".[323] This mechanism undermines the claim made by Gallaher that, if people smoked cigarettes solely to obtain nicotine "every cigarette smoker who uses nicotine chewing gums, inhalers or patches would stop smoking".[324] As the RCP noted:

    "The speed of nicotine delivery is a fundamental difference between cigarettes and NRT products which deliver nicotine at lower and slower subaddictive rates. For this reason, nicotine delivered through tobacco smoke should be regarded as a powerfully addictive drug and smoking as a means of nicotine self-administration. The risk of addiction to NRT products is very low ..."[325]

184. The true nature of the addictiveness of tobacco products has only gradually been recognized by public health authorities. As has already been noted, Gallaher drew attention to the fact that in 1964 the US Surgeon General defined the "tobacco habit" as "an habituation, rather than an addiction"[326] but by 1988 the same body described cigarettes as "addicting", going on to say that "the pharmacological and behavioural processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine". We have also previously drawn attention to Mr Martin Broughton of BAT's description of nicotine as having a "mild" pharmacological effect, similar to caffeine.[327] In our view this is both a dangerous and inaccurate statement. We were struck by recent research conducted at the John Hopkins University School of Medicine which compared the subjective and physiological effects of intravenous administration of nicotine and cocaine.[328] The key finding of this study was that, when given these drugs double blind, subjects frequently misidentified nicotine as being cocaine, or, at high dose, as an opiate. The study reported "At all three doses, cocaine was identified as a stimulant by the majority of subjects. Nicotine was also identified as a stimulant by 80% and 50% of the subjects at the intermediate and high doses, respectively."[329] The study goes on to say it is interesting that "when subjects were asked to identify the type of stimulant they had been administered, subjects usually identified both cocaine and nicotine as being cocaine or amphetamine and almost never identified either drug as being nicotine"[330] even though the subjects were familiar with both cocaine and nicotine. Nicotine produced a "rush" and a "high" that was dose-related and if anything greater than nicotine.

185. We submitted this article to BAT for comment, at their request. BAT, in their attempt to refute it, quoted selectively from the small print of the study's findings to support their view that "the study reported clear substantive differences between cocaine and nicotine and expressly stated that point".[331] This is hardly the point. It is evident that cocaine and nicotine have different effects - in particular, as the report points out and as BAT quote, nicotine produces more jittery and aversive effects while cocaine has consistently more pleasurable effects. The reason we cited this evidence was that, when the usual cues of a lit cigarette were not present, users found it difficult to discriminate between nicotine and cocaine or an opiate. They could have rated nicotine as being like caffeine, which would have fitted in with Mr Broughton's theories, but they did not. They perceived it to have a pharmacological effect similar to, perhaps even stronger than, cocaine.

186. We also cited the recent RCP report on Nicotine Addiction in Britain. BAT took issue with this report's central conclusion that nicotine is "highly addictive to a degree similar or in some respects exceeding addiction to 'hard' drugs such as heroin and cocaine".[332] Rather than providing a detailed and reasoned critique of the careful scientific review and analysis underlying a report produced by an extremely eminent group of individuals, BAT contented themselves with a series of superficial comments, and stressed that nicotine and hard drugs differed both in terms of the extent to which they produced intoxication and in their legal and social contexts. They objected to comparisons between drugs which indicate that quit rates and relapse for nicotine are even lower than from heroin or cocaine, which they described as "an illogical comparison since a relapse to smoking does not have the same personal and social consequences as a relapse to heroin, cocaine or alcohol".[333] This we find a fairly startling conclusion: it is hard to imagine more severe personal consequences than major diseases carrying a high risk of death.

187. Yet, as if to emphasize more poignantly and effectively the true - and to most people self-evident - nature of tobacco's addictiveness, about 50% of patients who survive an operation for lung cancer smoke again as do 40% of heart attack patients.[334] Any suggestion that smokers smoke primarily for the 'taste and flavour' is rather undermined when it is considered that 40% of laryngectomy patients smoke again, some even learning to smoke through their stoma.[335] Smokers themselves seem well aware of the difficulty of quitting - according to the latest General Household Survey some 69% of all smokers would like to give up,[336] around one third try to quit each year, yet only about 2% of smokers quit successfully each year.[337] Some 15% of all smokers have their first cigarette within five minutes of waking.[338]

A Tobacco Regulatory Authority

188. A consistent theme of the evidence submitted to us from the tobacco companies was that Government no longer engaged in a meaningful dialogue with them; confrontation had superseded cooperation. According to the TMA, the trade body representing the tobacco companies operating in the UK market, "There has been a marked reduction in the productive dialogue between the companies and Government, in particular in relation to the smoking and health issue".[339] Gallaher commented: "Regrettably, at the end of 1999 contact with Government is not as meaningful as it has been in the past ... a position Gallaher would like to see changed".[340] Imperial told us that it regretted the fact that "the constructive and effective relationship between the UK tobacco companies and the Government, which was epitomised by the consensual regulatory system created by the Voluntary Agreements, has broken down".[341] Mr Martyn Day, however, felt that the cooperative arrangements between the companies and the Government had benefited one side only: "I think that the whole approach of voluntary agreements ... was in the end one that worked in the tobacco companies' interests. It meant that they were always in negotiations and discussions. There is always that interplay which meant that the regulators became too familiar and were never keen to press too hard".[342] We believe that the Government is right to keep its distance from the tobacco industry which has, in our view, been the main beneficiary of the regime of voluntary agreements.

189. The final conclusion of the RCP in its Report Nicotine Addiction in Britain was that "an independent expert committee should be established to examine the institutional options for nicotine regulation, and to report to the Secretary of State for Health on the appropriate future regulation of nicotine products and the management and prevention of nicotine addiction in Britain".[343] We concur. It seems to us entirely illogical that treatments for nicotine replacement therapy are subject to stringent regulation whereas the infinitely more deadly tobacco products they are designed to supersede escape any fundamental regulation. So we believe a Tobacco Regulatory Authority should be introduced.

190. We have, throughout our report, indicated areas for which we think a Tobacco Regulatory Authority (TRA) could take responsibility. It could look at all aspects of the marketing of tobacco, the product itself and the nature of its health risks and developments in respect of 'safer' cigarettes. Smokers are addicted to nicotine in tobacco smoke. Yet the nicotine itself (contrary to what many smokers themselves believe) causes little harm.[344] It is the tar that accompanies the nicotine that does the damage. The companies themselves, in the 1960s, sought to isolate the carcinogens in tobacco, then gave up. We think that it is time that public health authorities addressed the issue of tobacco product safety. We think that those smokers who cannot quit are entitled to the safest possible product, and that no tobacco company can be trusted to give objective information on the safety of any of their products.

191. Consequently we would envisage the creation of a TRA with its own scientists, completely independent of the tobacco companies. When considering its function we should like to stress that we do not believe that the TRA could, for example, seek the elimination of nicotine from cigarettes. Its policies would have to recognize the realities of a global market for tobacco products, where any attempt to exclude nicotine - which would in our view be tantamount to prohibition of cigarettes, in that nicotine is, in the words of the RCP, the "unique selling point" of cigarettes - would be likely to be counter-productive. The proposed TRA could, however, examine nicotine:tar ratios to determine how these could be optimised to minimise exposure to toxins.

192. The TRA would, as we have stated, be the ideal objective judge of which additives and flavourings should or should not be permitted to be added to tobacco products, having as its test the overall impact on public health. The TRA could consider the marketing of tobacco products, looking at areas of promotion going beyond advertising into issues such as point of sale displays.

193. We would not expect the tobacco industry to welcome a regulatory authority with open arms - few industries would. We believe, however, that for too long the companies have enjoyed levels of commercial freedom entirely inconsistent with the fact that they produce what the Health Education Authority aptly called "by far the most dangerous consumer product on the market".[345] Given a clear steer by an appropriate regulatory authority, we believe that the tobacco companies could put some of their vast resources into devising alternative, safer nicotine delivery systems. For example, it has been suggested that tobacco deaths in Sweden have been reduced by the widespread use of a different nicotine delivery system, moist oral snuff, snus, which seems to pose a much lower health risk than cigarettes. We share the CMO's grave doubts that there will ever be a safe cigarette and his distrust of 'safer' products. Further, the gap between product reform and epidemiological data is large, so mistakes could prove extremely costly. Nonetheless, we do think that technological means to make cigarettes safer and less addictive should be explored and that a TRA could provide the necessary impetus for this. The TRA could, we believe, profitably set upper limits, and progressive reductions for known carcinogens.

194. In a research capacity, the TRA could examine, and offer definitive statements, on the current scientific consensus as to the dangers of smoking, and could examine the most effective ways of persuading people to quit or never to start.

195. Assuming there is a will on the part of Government to tackle nicotine addiction in the very fundamental way that we propose, the question remains where should a TRA be located? One possibility would be for the UK to have its own TRA, in a way analogous to the Food Standards Agency or Medicines Control Agency; another would be for a TRA to be located in Europe, the source of much of what currently passes for tobacco regulation.

196. As we have noted, the Secretary of State told us that he favoured "an independent scientific committee" at a European level to monitor and assess information on products.[346] The EU option has many attractions, in terms of the wider scale of the benefits it could produce to the total European population and those countries receiving tobacco products sourced in Europe. But we are not convinced that a European TRA could be set up in the near future. Furthermore, although the current Health Commissioner greatly impressed us in terms of his commitment to reducing tobacco consumption, we believe that the current CAP subsidy of tobacco undermines any credibility of a European TRA.

197. Accordingly, we recommend that the UK should institute a TRA with responsibility for all aspects of tobacco regulation consistent with the limitations posed by EU law. We would eventually like to see a Europe-wide TRA, but we feel that such a body would have no credibility until such time as the CAP subsidy for tobacco growing is eliminated.

198. Turning to the question of how the TRA should operate we think it vital that such a body should be very well resourced to deal with the huge scientific and legal resources of the tobacco companies. We think that a proportion of tobacco duty should be hypothecated to finance the regulatory authority. In oral evidence the DoH told us that, to analyse and understand the technical composition of cigarettes, it relied on a scientific adviser, Professor Frank Fairweather, who worked one day a week, another scientific advisor working two days a week, and Mr Tim Baxter who worked full time. Mr Baxter explained that, as head of the Tobacco Research Unit, he had access to a technical advisory group via the Scientific Committee on Tobacco and Health.[347] Finally the DoH provided over £500,000 a year to the Laboratory of the Government Chemist to test tar and nicotine ratings.[348] Mr Baxter recognized there were many calls on the Department's resources, but he admitted that it would be "very nice" to have more resources since his team were "highly stretched".[349] When we put our concerns on this matter to the Secretary of State he agreed that the tobacco team in the Department was "quite small", but he contended that its work was supplemented by, for example, the professionals working in Health Action Zones and the Scientific Committee on Tobacco and Health. This latter body he described as "a very useful organisation".[350]

199. We would have more faith in the Secretary of State's assessment of the added benefit of SCOTH had that organization not been in abeyance for almost two years. We regard the current staff resources devoted to tobacco control, especially in the area of scientific knowledge and advice, to be pitifully weak. Irrespective of whether the Secretary of State accepts our recommendation that root and branch reform is needed in terms of a TRA, we would expect to see a major increase in resources, met out of the enormous income the tobacco companies pay in duties to the Treasury.

200. If UK staff resources are pitiful, those in the EU are utterly derisory. As the Secretary of State informed us, and as we saw for ourselves in Brussels, in Europe "there is just one official dealing with tobacco", Mr John Ryan.[351] In fact the situation is graver still, in that tobacco forms only one half of Mr Ryan's portfolio. We met Mr Ryan on our visit to Brussels and were extremely impressed by his knowledge and commitment. But we do not see how the Health Commissioner can deliver his objective of reducing tobacco consumption with such scant resources. We recommend that the Secretary of State makes immediate and urgent representations in Brussels to create a far more substantial unit to combat the enormous resources of the tobacco industry. We believe that European policy is already hugely compromised by the CAP subsidy, and that unless appropriate resources go into tobacco control European action in this sphere will lack credibility.


320   Pharmacia and Upjohn Discussion Paper 1, p.7. Back

321   Nicotine Addiction in Britain, p.185. Back

322   Ev., p.639.  Back

323   Pharmacia and Upjohn Discussion Paper 1, p.7. Back

324   Ev., p.183. Back

325   Nicotine Addiction in Britain, p.184. Back

326   Ev., p.184. Back

327   Q573. Back

328   H E Jones et al, "Subjective and physiological effects of intravenous nicotine and cocaine in cigarette smoking cocaine abusers", The Journal of Pharmacology and Experimental Therapeutics, 1999:288, pp.188-97. Back

329   ibid, p.196. Back

330   ibid, p.196. Back

331   Ev., p.570. Back

332   Ev., p.570. Back

333   Ev., p.578. Back

334   Ev., p.63. Back

335   Ev., p.488. Back

336   GHS 1998, p.140 Back

337   Nicotine Addiction in Britain, p.186. Back

338   GHS, p.142. Back

339   Ev., p.280. Back

340   Ev., p.191. Back

341   Ev., p.223. Back

342   Q1229. Back

343   Nicotine Addiction in Britain, p.189. Back

344   Ev., p.16. Back

345   Ev., p.18. Back

346   Q1320. Back

347   QQ59-60. Back

348   Q61. Back

349   Q63. Back

350   Q1265. Back

351   Q1266. Back


 
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