Select Committee on Health Appendices to the Minutes of Evidence


APPENDIX 19

Memorandum by Pharmacia and Upjohn (TB 33)

INTRODUCTION

  1.  Pharmacia and Upjohn is a major research based pharmaceutical company. It pioneered the development of Nicotine Replacement Therapy (NRT) medicines, the total market for which is currently worth approximately £50 million in the UK. (This is circa 0.5 per cent of consumer spending on tobacco products at retail prices.)

  2.  Pharmacia and Upjohn is committed to the reduction of smoking related harm, and supporting informed public debate on the appropriate use of NRT and other inventions to promote smoking cessation and reduction. This brief memorandum summarises and develops arguments contained in the P&U discussion paper Smoking, Nicotine and Society, copies of which accompany this submission.[20]

THE ADDICTIVENESS OF NICOTINE

  3.  Inhaled nicotine in tobacco smoke is highly addictive. Awareness of this fact led to our original research interest in the development of NRT medicines, which dates back to the 1950s. Nicotine taken in other ways may be regarded as less addictive, in as much as ingestion is slower and levels of nicotine in the blood are more stable.

  4.  Slower delivery and stable nicotine plasma levels reduce the association between consumption and perceived reward. NRT helps people to stop smoking, in part by breaking the association between experienced rewards and smoking related behaviours. Nevertheless, all forms of nicotine use can result in physiological changes in the brain and elsewhere in the body.

THE DIRECT HEALTH CONSEQUENCES OF NICOTINE USE

  5.  In sufficient amounts nicotine is highly toxic. However, in the doses taken by smokers (who are able to self-titrate their use of the drug with considerable consistency) there is little evidence of direct harm. Claims of complete safety should always be avoided. However, in general it is correct to say that dependent smokers smoke for nicotine, but are disabled and killed by other components of tobacco smoke. Nicotine ingested via NRT medicines causes very much less risk to health than tobacco smoking.

  6.  There are misleading (and perhaps on occasions deliberately fostered) "myths" about it being hazardous to use more than one form of NRT at the same time, and/or to use NRT without completely quitting smoking2. In reality people appear to be as able to titrate their nicotine doses in these circumstances as when they are using tobacco. There is evidence that simultaneous use of different forms of NRT can improve quit rates through better control of nicotine-linked smoking withdrawal symptoms, and a logical case for believing that smoking reduction (as distinct from complete cessation) is beneficial to both smokers and those who share their environments.

POTENTIALLY COUNTER-PRODUCTIVE RESTRICTIONS ON THE USE OF "SAFER NICOTINE"

  7.  Pharmacia and Upjohn does not wish to present its NRT products in forms other than medicines, or in any way to fail to comply with the terms of their licences. However, it follows from the facts set out above that there is a potentially strong public interest case for the use of relatively safe nicotine containing products as substitutes for relatively dangerous tobacco products.

  8.  This has for many years been argued by leading independent authorities on the treatment of addiction3, and is beginning to be reflected in Scandinavian approaches to NRT medicines licensing. In this country some forms of NRT have recently been licensed for general sale, in any type of retail outlet. Yet despite this progress and welcome advances in areas such as the establishment of new NHS smoking cessation services, UK policies in this area could, along with those of most other countries, still be regarded as too conservative.

  9.  While tobacco products remain easily and conveniently available, the restraints on most NRT products may mislead consumers into believing that they are hazardous to use. The least educated and socially advantaged sections of the population, who today are the heaviest users of tobacco, are likely to be particularly vulnerable to such misunderstandings. (Some forms of nicotine replacement therapy are still confined to prescription only status. There are also inconsistencies in the age related supply regulations for NRT as compared to those applying to tobacco products.)

  10.  To the extent that failures to apply modern scientific knowledge of the harmful effects of smoking and the addictiveness of nicotine have served to preserve high levels of consumption of "dangerous nicotine" in tobacco products, lives are being needlessly lost. Inadequately informed policies may be harming rather than protecting public health, and helping to promote rather than reduce class linked inequalities in health.

SCIENTIFICALLY INFORMED POLICY FORMATION

  11.  Senior representatives of organisations such as the WHO have already expressed support for the concept of NRT use for smoking reduction4, as well as for stopping smoking. Tobacco smoking is still killing 120,000 people a year in the UK alone. At any one time the number of people disabled or impaired by smoking will be at least an order of magnitude greater. From a pragmatic perspective there would appear to be little to lose and much potentially to gain from more radical attempts to encourage increased "safer nicotine" use, provided that due care is taken not to permit activities which might deliberately create new generations of nicotine addicts.

  12.  Such suggestions are often, however, greeted with suspicion, and apparent prejudice. This may in part be linked to the fact that groups in society other than the tobacco industry and smokers themselves have complex vested interests in tobacco smoking, and/or the sale of goods and services which relate to it and its possible consequences. Stakeholders in the smoking and nicotine field include pharmaceutical companies, the health care professions, large and small retailers, and media organisations.

  13.  Politically, sensitivities relating to voter opinions on addictions, and illicit as well as legal drug use, may discourage rational policy debate. However, the main political parties in the UK share a common long term commitment to public health improvement, and the further reduction of tobacco related harm.

  14.  To this end arguments in favour of more liberal approaches to the licensing and supply of NRT medicines to support both smoking cessation and reduction deserve balanced, objective, analysis. Pharmacia and Upjohn will do all it can to support this.

REFERENCES

  1.  NHS Centre for Reviews and Dissemination (1988). Smoking Cessation: What The Health Service Can Do. Effectiveness Matters 3, 1. NHS CRD, The University of York, York.

  2.  de Guia, N (1999). Rethinking Stop Medications. Ontario Medical Association Position Paper. OMA, Ontario.

  3. Russell M A H (1991). The Future of Nicotine Replacement. The British Journal of Addiction 86, pp 653-658.

  4.  Yach D, (1998). Control of Tobacco in the Twenty First Century. Paper presented at the Third International Heart Health Conference, Singapore.


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