Examination of witnesses (Questions 360
- 379)
THURSDAY 9 DECEMBER 1999
PROFESSOR JOHN
BRITTON, DR
JENNY MINDELL,
SIR ALEXANDER
MACARA and DR
BILL O'NEILL
Mr Austin
360. To take the cigarette as a nicotine-delivery
vehicle, it has certainly been suggested that the tobacco companies
have tried to define the addictiveness of nicotine as a habit
and I have to say I did make a comment in the earlier session
that even the Tobacco Advisory Council seem to use the words "dependency",
"habit" and "addiction" almost interchangeably.
There is this sort of suggestion that it is a habit a bit like
shopping on the Internet, that it is a little damaging. Would
you like to tell us something about the medical view of the nature
of the addictiveness of tobacco?
(Professor Britton) Nicotine "addictiveness"
and "dependency" are words that can be used interchangeably
for practical purposes. The addictiveness of nicotine is determined
partly by the drug itself and partly by how it is delivered.Cigarettes
deliver nicotine in a very rapid dose into the arterial blood
to the brain and it is that form of delivery, plus the drug itself
which is important. In that circumstance, the evidence that the
College has recently put together in a report which our submission
to the Committee is based on is that nicotine is as addictive,
on a par in terms of addictiveness to heroin and cocaine, so to
the major drugs of abuse and harm in this society, illegal drugs
of abuse.
361. When did you reach the conclusion or when
did the medical profession generally reach the conclusion that
nicotine was addictive?
(Professor Britton) There is reference to the fact
that nicotine may well be addictive in the 1962 first Royal College
of Physicians Report. I think that the bulk of evidence that our
current report relates to has come through over the last ten years
or so, between the 1980s and 1990s. I think that is right.
362. You have indicated that there is a comparison
with other drugs of dependence, what are often described as "hard
drugs".
(Professor Britton) Yes.
363. I think some of us might think given the
nature of the evidence that nicotine should be classified as a
hard drug.
(Professor Britton) Yes, it should be.
364. What objective research has been shown
to demonstrate that nicotine is this powerful addictive drug on
a par with those other drugs?
(Professor Britton) There is extensive work in animals
showing similar levels of drug-seeking behaviour for nicotine
as for cocaine and heroin. The ranking of relative addiction varies
according to the experimental system used. Drug behaviour in humans,
dependency is defined in relation to certain set criteria from
the American Psychiatric Association and from the ICD, the International
Classification of Diseases definitions. Nicotine meets those criteria
just as clearly as do other hard drugs of addiction and I do not
think there is much distinction to draw between them. The main
difference is firstly that nicotine does not produce intoxication
and perhaps has not been seen historically as such a problem in
society, and secondly that it is legal.
365. So apart from the fact that it is addictive,
the damage is the delivery vehicle in which it comes?
(Professor Britton) In theory, there are some potential
ways in which nicotine may be harmful in its own right. They are
very, very small effects. In terms of the total damage done by
cigarette-smoking, it is minimal, negligible in relation to the
harm done by the vehicle.
Dr Brand
366. Given the addictive nature of nicotine,
do you think we have got the policy right in supporting people
that want to withdraw from this drug?
(Sir Alexander Macara) I think we have got the policy
right in wanting to help people.
367. That was not the question.
(Sir Alexander Macara) Thank you. I hoped the question
was: are we doing enough? The answer is no, of course we are not.
Smoking Kills, which was launched almost a year ago, was
a very good start in a statement of government commitment to assist
people to quit smoking. What we particularly regretted was the
restricted nature of the specific support which could and should
be given through nicotine replacement therapy and I know that
Professor Britton in particular has strong feelings about that;
we all do. It seems very regrettable that the ability for doctors
to prescribe for their patients an effective drug which would
really effectively help them is so restricted.
368. How long, this is to you or Professor Britton,
would you normally think there was a need for nicotine replacement
during the withdrawal phase?
(Professor Britton) The evidence is that nicotine
replacement has most of its effects within the first few weeks
of treatment and after about six weeks or so there is little incremental
extra benefit.
369. So if you were going to make a recommendation
to the Government, you would say that rather than having a week's
supply to a very limited number of people in health action zones,
you would make six weeks' supply available presumably in weekly
bits so that people need to keep in contact with their—
(Professor Britton) There are two points there. The
first is that there is limited supply to a limited number of people
in health action zones. People in health action zones qualify
for nicotine only if they qualify for free prescriptions, so in
fact the coverage of the availability of nicotine replacement
therapy at present is less wide than the White Paper perhaps implies.
Chairman
370. So it is people on free prescriptions in
health action zones for a week?
(Professor Britton) Yes, for a week. It is not people
just living in health action zones, so in terms of postcode prescribing,
which was the bite on the radio last night, health action zones
are a particular example of how it should not be. You need to
be living in the right postcode and to have free prescriptions
to get one week of nicotine.
(Dr Mindell) I think even then you actually have to
be referred to a specialist smoking clinic.
(Professor Britton) Yes, so there are many barriers
to getting it. The second thing is that most people who are going
to fail have failed by about a week and, therefore, if you make
supplies of nicotine conditional on success up to a certain point,
there are enormous potential savings to make. To give every smoker
who says "I would like to give up smoking" six weeks
of nicotine over the counter now would be very wasteful.
Dr Brand
371. You believe that there is a distinct role
for nicotine replacement therapy as part of a Stop Smoke programme?
(Sir Alexander Macara) The important point is as part
of, is it not?
(Professor Britton) Nicotine replacement therapy works
if you buy it over the counter, it just may not work quite so
well. Nicotine replacement therapy is one of the most cost-effective
medical treatments available. It is the only one that is effective,
that I am aware of, that is not prescribable.
(Sir Alexander Macara) It will work particularly well
within the context of the general practitioner or health adviser
supporting and counselling the individual, which is why it is
important that general practitioners are able to prescribe it.
372. The Glaxo Wellcome drug, Zyban, is that
something that should be evaluated as a matter of urgency by the
National Institute for Clinical Excellence?
(Dr O'Neill) It is very difficult to measure the word
"urgency" in the context of the National Institute at
the present time when there are so many things on the agenda.
There is no doubt about it, the drug needs to be evaluated and
a decision needs to be taken on whether or not it is going to
be available in this country.
(Professor Britton) The drug clearly works, as nicotine
replacement does. Smoking kills 50 per cent of smokers and here
is an effective treatment which will reduce that risk, it seems
stupid not to take it on. In terms of the economic arguments,
medicine embraces many incredibly expensive treatments. Drugs
that lower blood fat levels are a classic example. An estimate
in the press last week was of about £5,500 per life year
saved and smoking comes out at between £200 and £800
depending on how you deliver the service. It is remarkably good
value. It is quite low tech and a bit simple and I think that
is perhaps why it does not get quite the kudos of other interventions.
(Sir Alexander Macara) There is just one point I would
like to clarify. I expect Dr Mindell has another point. I would
not like it to be thought that we are being critical of the concept
of Health Action Zones. It has to be a good thing that there are
opportunities there to target those people most in need of help
and support of all kinds. It is also a good thing that nicotine
replacement therapy will be evaluated. The important point Professor
Britton was making was that the timescale in which that is to
be permitted is far too short to produce the results that we would
wish to see. I am sorry, I cut across Dr Mindell.
(Dr Mindell) I wanted to add that smoking cessation
support is really in two parts, one of which is what we were talking
about just now about measures to help those smokers who have decided
that they would like to quit and to help them at an individual
level, but the public health policy level that requires Government
action, apart from support at this individual level, is equally
important, measures like banning all forms of tobacco promotion,
increasing the price consistently above inflation, preventing
smoking in public places. All these types of approaches are just
as important in encouraging smokers to try to stop, in enabling
them to remain stopped and in reducing the number of adult smoking
models that influence young people.
(Dr O'Neill) The other thing we must add to all of
this is the fact that clearly the case for nicotine replacement
therapy is proven. Having said that, we still have a situation
where many people have contact with health professionals and are
not asked something as simple as their smoking status. I know
you have had evidence submitted here of the work of Professor
Fowler in the late 1970s and early 1980s who, as a general practitioner,
advocated the fact that every general practitioner should ask
a patient about their smoking status, should give them brief advice
and possibly add nicotine replacement therapy to that. That has
been demonstrated to be effective. I think there is a case to
answer for every doctor, nurse and health professional in the
country, whether they are asking patients about their smoking
status, whether they are advising them about the benefits of stopping
smoking and, indeed, what doctors, nurses and others are doing
themselves about their smoking behaviour. I think that is a very
important message that we must get across.
Chairman
373. Could I come back to regulation. Dr Mindell,
you described broadly your thoughts on what should be included
in the regulation. I do not know whether your view collectively
is that that regulation should be national or EU-wide. There is
another point I want to make before I raise another issue about
the "light" cigarettes, a question which Sir Alexander
raised. What are your views on the actual regulation of nicotine
and whether nicotine can be effectively regulated out of these
products in some way?
(Dr Mindell) Can I start by saying that in tandem
with deciding you can regulate nicotine out, or whether you should
regulate it out, you need to know what you are regulating. The
measurement of nicotine and tar is crucial. At the moment we have
a completely flawed system. Low tar, low nicotine cigarettes actually
contain almost identical amounts of tar and nicotine to not low
tar ones. The difference is that when you smoke it, as smoked
by those machines that are designed for these regulatory purposes,
the amount of tar and nicotine is much lower than in the earlier
designs of cigarette. That is not the same as when a smoker smokes
it. As we have already heard, people who change from medium or
high to low tar and low nicotine cigarettes inhale more deeply
and leave a shorter stub because they are trying to maintain the
same nicotine fix that they were getting on the previous cigarette.
The other thing that has become known more recently is the way
that tar and nicotine is lowered is through microscopic holes
which happen to be where a smoker's lips or fingers would be and
when those holes are covered you do not have this lowering effect.
One of the things that has to be done is to develop some form
of measurement that actually measures what is important rather
than measures what customers are currently being told. Personally
I am not bothered whether these regulations are at the EU or at
the national level. The advantage of the European level is that
they will be of benefit to more people. Whichever is easier to
implement. Having them at a national level does not preclude,
and may even strengthen, European moves to have them across Europe.
I do not think that this Government should necessarily wait for
European Directives. On the other hand, if that is considered
a better or faster or more comprehensive way then that is fine.
374. Coming back to the issue of low tar, so-called
"light" cigarettes, Sir Alexander made a point about
completely banning advertising and marketing. Presumably you would
be against a packet having somehow a claim in the title that was
low tar or implicitly less harmful, would you?
(Sir Alexander Macara) I think we do have to look
at the language, the words that are used. I think we are entitled
to restrict the words that can be used in the marketing to make
sure that they are not misleading, whatever these words are.
Chairman: Do any of my colleagues have further
questions to ask?
Audrey Wise
375. I would just like to get absolutely crystal
clear from all four of you the question of the cost effectiveness
of, say, six weeks appropriate prescribing by GPs of nicotine
replacement therapy. If we made such a recommendation, for example,
and obviously I do not know whether the Committee would be minded
to do that or not, could we be shot down in flames on cost grounds
or would we be able to back up such a recommendation and show
its cost effectiveness as well as its effectiveness?
(Professor Britton) This is a document called Smoking
Cessation Guidelines and Their Cost Effectiveness, which was
published a year ago, and the second part of this section is written
by health economists primarily who looked at the effectiveness
of different models of providing smoking cessation services. We
will leave this document for you. As I said earlier, those costs
come out at somewhere between £200 and £800 per life
year saved depending on what model one adopts, some are broad
reach, some are restricted access. In terms of health cost effectiveness,
smoking cessation is one of the most cost effective interventions
available to us. I think the median cost effectiveness of the
top one hundred medical interventions shown to prolong life—and
it surprises me sometimes that there are one hundred medical interventions
that prolong life—is about £17,000 per life year saved.
Smoking is under £1,000. That is with six weeks of nicotine.
376. I appreciate that this is not intended
as being an alternative to public health measures but you all
concur?
(Dr O'Neill) Absolutely. Just to reiterate the point
that Professor Britton made earlier on, if someone is using the
nicotine replacement therapy and after a week they are still smoking
then there is no benefit in them continuing. We would not want
to give you the impression that we think everybody should immediately
get a six weekly prescription.
377. No, I said "appropriate".
(Professor Britton) I think these are worked out on
six weeks so it might be slightly cheaper than that.
(Sir Alexander Macara) It is not either/or. Helping
individuals or promoting and protecting the public health, it
has to be both together.
378. It has been suggested to us as well, and
I do not know whether you agree with this, that nicotine replacement
therapy increases the effectiveness of other forms of health or
support or intervention. Is that so?
(Professor Britton) It doubles the success. Roughly
speaking, whatever else you do is doubled by nicotine, which is
why I said earlier that nicotine—
379. By nicotine replacement therapy?
(Professor Britton) By nicotine. Which is why I said
earlier that nicotine over the counter without any support at
all is probably doubling the chance of success of somebody who
goes into a chemist and thinks "I think I might try to stop
smoking", or "I am going to get something to help me".
In general, the more one puts into smoking cessation, the greater
the return. Bupropion, in so far as it has been studied, seems
also to have a similar incremental effect on top of whatever else
you do.
Audrey Wise: So it seems from that that the
most cost effective intervention is, as Dr O'Neill suggested,
GPs advising and helping and discussing plus nicotine replacement.
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