Examination of witnesses (Questions 120
- 139)
THURSDAY 18 NOVEMBER 1999
PROFESSOR LIAM
DONALDSON, DR
DAWN MILNER,
MR TIM
BAXTER AND
MR PAUL
LINCOLN
120. I think the implication of the Health Education
Authority evidence and the implication of my question is not a
criticism of the regulation of NRT, it is to point up this contrast
that something which is actually being used with benign intention
and is less dangerous is more regulated because it is correctly
evaluated on its pharmacological consequences, whereas tobacco
is not and you agree there is no justification for that. How effective
do you think that the nicotine replacement therapy currently available
to smokers who want to quit actually is? Should it be stronger
products or are the products okay? Should there be free provision
of this as an extra incentive? I note that there will be one week's
free NRT available to people, but is one week meaningful or not?
(Professor Donaldson) The evidence shows that it is
not terribly successful if it is part of an isolated programme.
If it is part of an overall programme targeted at all the areas
that are in the White Paper, including the promotion of tobacco
and the advertising of tobacco then it does have an impact and
that has been shown in other countries. You have also got to bear
in mind that the addictive element of it has to be balanced against
other pressures, particularly peer pressure on children and image
and things of that sort. So you cannot simply assume that a straightforward
nicotine replacement therapy in children will work on its own.
You have to target other health education measures against the
individual. I think it has its part to play. We have got some
figures in the White Paper about predictive cessation rates for
people who are part of programmes, although I cannot immediately
call that to mind.
(Mr Baxter) I think there is certainly plentiful evidence
on the effectiveness of NRT. It was published about a year ago
in Thorax by the journal of the British Thoracic Society.
It doubles the success of any quit attempt regardless of the intensity
of the intervention. Basically it is an effective route to smoking
cessation so long as you take the full course.
(Dr Milner) What Tim says is correct, that the use
of NRT doubles the effectiveness of the intervention. If the intervention
is simply brief advice from the GP that you should stop smoking
and then you add on to that advice to use NRT you will increase
your effectiveness from two to four per cent. At the other extreme,
if you have a smoking clinic with regular group therapy sessions,
with follow up and relapse prevention and the use of NRT you will
be getting quit rates perhaps up to 20 per cent or even higher
from various studies. So it is effective and it is cost-effective.
You asked about whether the dose should be larger. The thing about
the nicotine replacement products is they use a different route
of administration of the cigarette. The cigarette gets your nicotine
straight through into the blood supply very quickly and into the
brain in a matter of seconds. This cannot be achieved by any of
the current NRT products. They either rely on absorption through
the skin, the patches, or through the lining of the mouth, the
gum; the inhalator also is not actually inhaled, the nicotine
is absorbed through the mouth. With all routes of absorption it
does not provide a peak blood level of nicotine, it produces a
slower rising blood level and a lower level of nicotine within
the blood than does the cigarette, which gives you a peak hit.
So there are not any products that I am aware of that provide
that hit like cigarettes. It is not a question of strength, it
is a question of route of administration.
121. It strikes me that that actually could
be a beneficial side of it because you are able to have this drug
but in a way which may be a genuine way of helping to relieve
addiction?
(Dr Milner) Yes, and if the drug is administered in
a way through the nicotine replacement therapy it does not seem
subject to abuse because it does not give you a hit, so the drug
nicotine becomes an addictive drug when it is administered through
the lungs through a cigarette. There are people who continue to
stay on the nicotine gum for life and become dependent in some
way on that form of nicotine, but generally it is not open to
abuse like the cigarette.
122. So one week seems very short. Would it
not be sensible, in view of the clear value, to make free availability
for a longer time, perhaps if it were made conditional on having
a bigger package or something? Would that not be a good use of
resources?
(Mr Baxter) I think the answer is that the Government's
policy on that is to offer a week to help people through the initial
stages, that the first week is the worst, and poor smokers have
a free week of NRT, and then the argument is that actually the
cost of cigarettes and the cost of NRT are roughly comparable,
so you are actually saving the money from providing NRT.
123. But you are reducing one of the things
that you can say to people, "Put the money in a jar and then
you can use it for a holiday." If you say, "This is
going to cost you as much"—
(Mr Baxter) Only for eight weeks, I would say.
124. Only for eight weeks, and then it should
have worked in eight weeks?
(Mr Baxter) Yes, ideally.
125. In that case that is an even better reason
for doing it through a proper free package. How much is a week
going to cost, do you think? What is the estimated cost of the
Government's present programme?
(Dr Milner) If somebody buys it over the counter it
will be—
126. No, I mean of giving a free week. What
do you think? The Government must have said, "This is likely
to cost X amount"—only an estimate, of course?
(Mr Baxter) Of the £60 million in the White Paper
over three years, I think it was reckoned that about 12.5 per
cent. of that would go for the free NRT, so it is £7.5 million
of that.
Audrey Wise: £7.5 million over three years.
That is a tiny amount.
Dr Brand: On a point of information, Mr Chairman,
this is not freely available to everybody who wants to stop smoking.
It is only in Health Action Zones, so it is a very small proportion
of the population that gets a tiny bit of help. It would be nice
if the extra taxation on cigarettes announced this week would
all have been spent on smoking cessation.
Audrey Wise
127. Has there been any discussion about making
it wider or longer or both?
(Mr Baxter) Indeed. Yes, you are quite right, Dr Brand,
it is only Health Action Zones this year but the programme will
go wider from April next year. I think it is fair to say that
the Government wants to see how this works in practice before
putting more top-slice money into this. This does not stop health
authorities, if they regard it as a priority, putting extra money
in and some health authorities do this already.
Dr Brand
128. They have such a lot.
(Mr Baxter) So it is not something the Government
is saying we will not return to but they want more evidence of
the effectiveness actually in practice as opposed to the academic
clinical trials.
Chairman
129. Is there a problem with Government over
the principle of offering NRT in these circumstances, bearing
in mind that there are other addictions with health implications
to which the principle may be applied as well quite effectively,
alcohol abuse, for example?
(Professor Donaldson) I do not think there was any
thin-end-of-the-wedge argument, it was simply a question in the
first phase of funding of deciding on the balance between different
strands of the package.
Audrey Wise
130. The Chairman has given me permission to
carry on a little bit and your yourself did mention the word "children".
Of course, this is one of the disappointing things, that the targets
for children and young people are not being met. What do you think
can be done in pursuit of more effective methods in relation to
stopping children smoking?
(Professor Donaldson) There are a number of points
to make. The percentage reduction targets to reduce smoking amongst
children that you have mentioned, we have to remind ourselves
that these are new generations of children growing up each time,
so it is not a reduction within a static cohort. They are fresh
cohorts and all the evidence shows that if you are trying to get
health eduction across to children you have to be fresh and new
and of the moment. I used to give a lecture years ago when I would
put a baseball cap on halfway through the lecture with a straight
brim across it and point out from a slide that I showed that there
is no child in the world would use a baseball cap like that; they
would bend the brim before they put it on. So that shows the subtlety
of influence on children's behaviour, but it shows that these
things are worldwide and if you go out as somebody's dad wearing
a baseball cap with no curves on the brim your children will not
want to walk alongside you.
Chairman
131. I think William Hague found that.
(Professor Donaldson) So the point I am making there
is that in giving health education advice we have to be very sophisticated.
We have to be of the moment and we have to give children information
which will help them to combat peer pressure from their colleagues.
So the health education has to be very well-designed. The promotion
and advertising is probably a much bigger part of the programme
as far as children are concerned as compared to adult smokers
and you are probably aware of the research in which the Joe Camel
carton character was used to promote cigarettes in the United
States and I think it was 90 per cent. of 6-year-olds who knew
that it was associated with tobacco and that was as high as the
proportion that recognised Mickey Mouse. So these sorts of issues
are very important for children and so I think the combatting
of advertising and promotion will probably have the biggest impact,
backed up by health education in schools.
Mr Burns
132. Very briefly, I think that is absolutely
right but one part of the equation also which must be crucial
surely is enforcing the existing laws on the sale of tobacco products.
(Professor Donaldson) Yes.
133. In my own area about a month ago a survey
was done which found that a significant proportion of newsagents
and tobacconists were selling cigarettes to anybody, obviously
in defiance of the law. What can be done to make sure that existing
laws in a critical area are made enforceable?
(Professor Donaldson) That is a very important point
and the Government introduced an element within the White Paper
on tobacco to address this and Mr Baxter might like to say a few
words about that.
(Mr Baxter) You are absolutely right. We have had
legislation banning sales to children since 1908 but enforcement
is a real issue and we work with the local authority co-ordinating
body on food and trading standards on the development of an enforcement
protocol for local authorities. We have also tried to raise the
issue of awareness of the issue amongst magistrates because apparently
not very many prosecutions are brought and the most serious offenders
are prosecuted and they are getting really fairly low fines. So
we have sought to raise awareness of the issue. I do not think
in any shape or form we have got it right yet. It is an important
issue which we will have to continue to press on but the Government
has also proposed in the White Paper the possibility of an offence
of repeated sales to children.
Once we get existing local difficulties with
the advertising regulators out of the way we can try and pursue
that. It is an important area and I cannot pretend that we have
got it right yet.
134. Why do you have to wait until something
else has been done before seeking to get more effective enforcement
of the law?
(Mr Baxter) I was talking about the new offence. It
is simply a matter of resources within my team.
135. Would it come from your team rather than
the Home Office?
(Mr Baxter) We would initiate it with the Home Office.
We have already had preliminary discussions with them.
Audrey Wise
136. I agree about the importance of enforcing
the law, but there is also the issue of relieving the pressure
of demand as well which is very important, i.e. encouraging kids
not to smoke. I see from the report of the Scientific Committee
on Tobacco and Health that it is known that nearly all ten to
11 year olds do not smoke and by about 15 years of age 30 per
cent have become smokers, so there is a huge change. The ten and
11 year olds who are not smokers can still be rational about it
whereas once people become addicted they become totally irrational.
What path, for instance, is outlined in the National Curriculum
about this? Is it just left to schools? A primary school class
in my constituency with children possibly even younger than this
wrote to me expressing their distaste for smoking and it was obvious
that they had taken this into the home as they were critical of
their parents. They were extremely rational letters from very
young kids. It was a lot of work for me, but I thought that was
a really good initiative. Is there any proper encouragement or
even requirement for primary schools to do this sort of thing?
(Professor Donaldson) Dr Milner can comment on the
National Curriculum. If I could just add one further statistic
which I think is relevant and that is that studies have shown
that if you look at the teenagers that take up smoking and follow
them through to the age of 30, the majority of those who are from
relatively affluent families have given up by the age of 30. Those
who are from poor backgrounds do not give up on the same scale.
There is a very important issue in that second phase from teenage
years through to early adulthood. Dr Milner will comment on the
National Curriculum.
(Dr Milner) My understanding is that within the framework
of the personal health and social education component of the National
Curriculum tobacco may appear on three occasions during the school
year as part of general drug education that would be included
within those sessions that are set aside for what is called personal
health and social education.
137. At what age?
(Dr Milner) I believe this is right through the school
year.
Chairman
138. Is that each year?
(Dr Milner) Yes.
Audrey Wise
139. The report of the Scientific Committee
on Tobacco and Health which was published last year talks about
having a clearer focus on prevalence in 14 and 15 year olds. There
is a sort of implication that that is where it is important in
the National Curriculum. I am just wondering whether we are missing
an opportunity to turn the non-smokers aged ten and 11 into anti
smokers. It could give them an adult feeling that instead of copying
their parents they are actually taking a critical look at their
parents. Is there enough emphasis on this?
(Mr Baxter) I think it is fair to say that certainly
our experience is that until children hit around about 12 or 13
they tend to be extremely active on anti smoking. They are the
best zealots we have. Something happens to them around puberty.
I think Mr Lincoln could comment from the Health Education Authority
perspective on the success or otherwise of campaigns aimed at
young people. It is incredibly hard, but that does not mean we
should not go on trying.
(Mr Lincoln) This is a very difficult area, much more
difficult than looking at the situation with respect to adults.
There is very little evidence of the effectiveness of programmes
with young people that we are aware of around the world. We did
convene a group of experts from around the world to look at what
could be done in terms of comprehensively tackling the smoking
issue with young people and we would be happy to furnish the Committee
with that group of experts' views. It is a comprehensive approach
that is required and that is advocated in the White Paper in relation
to this area and it is well worked out in relation to adults.
School health education programmes have been disappointing and
so has teenage cessation. It does not look promising in terms
of the early studies that have been done on this. One of the most
powerful things that has been done is the advertising ban because
the Smee Report by the Department of Health Chief Economist showed
that that did have a big impact in reducing children's smoking
when one looked at the effective programmes such as those in Norway.
The general view about health education programmes in relation
to young people is that they are more influenced by adult programmes,
that is what the evidence seems to suggest. All age programmes
tend to be more successful than targeted programmes. That does
not mean to say one should not continue to invest and try and
find an effective way of including it in education. A more holistic
approach rather than just focusing on tobacco also seems to have
been indicated as the most effective approach. Again, this is
an area where a lot of research is being done. Unfortunately,
results worldwide are not that promising.
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