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9 Summary and recommendations

9.1 Tobacco and nicotine addiction
9.2 Consequences of nicotine addiction
9.3 Treatment of nicotine addiction
9.4 Regulation of tobacco products
9.5 Recommendations
References

Cigarette smoking is the single largest avoidable cause of premature death and disability in Britain, and thus presents both the greatest challenge and the greatest opportunity for all involved in improving public health. The eradication of smoking from Britain would realise massive health gains, particularly for the most disadvantaged sectors of society. The prevalence of smoking in Britain has fallen substantially since the health risks of cigarette smoking first began to be publicised, but now appears to be stabilising at approximately one in four British adults. To achieve further significant reductions in smoking prevalence it is necessary to look more radically at the causes, treatment and ultimate prevention of smoking behaviour.

The central conclusion of this report is that cigarette smoking should be understood as a manifestation of nicotine addiction, and that the extent to which smokers are addicted to nicotine is comparable with addiction to 'hard' drugs such as heroin or cocaine. This conclusion has fundamental implications for the design and implementation of public health policy on the control and prevention of cigarette smoking.

9.1 Tobacco and nicotine addiction

The unique selling point of tobacco is its nicotine content - tobacco products without nicotine are not commercially viable. Nicotine is an addictive drug, and the primary purpose of smoking tobacco is to deliver a dose of nicotine rapidly to receptors in the brain. This generates a pleasurable sensation for the smoker which, with repeated experience, rapidly consolidates into physiological and psychological addiction reinforced by pronounced withdrawal symptoms.

The presence of nicotine is necessary, but not sufficient, for the nicotine to have a powerful psychoactive impact. To achieve the latter, nicotine must also be delivered rapidly to the brain. 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. The potency of the nicotine effect is created by the speed of delivery, not just by the total nicotine delivered. The speed of nicotine delivery is a fundamental difference between cigarettes and nicotine replacement therapy (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 the means of nicotine self-administration. The risk of addiction to NRT products is very low, but they are effective in attenuating cravings and withdrawal from tobacco-delivered nicotine dependence.

In its usual dose range, nicotine use does not cause intoxication or intense euphoria, but does have a complex physiological impact which creates dependency reinforced by withdrawal. The fact that nicotine does not intoxicate does not make it less addicting, but may explain why medical bodies and governments have not generally recognised tobacco use as a form of drug addiction or dependence. It is far from clear that benefits attributed to nicotine use such as stress relief, improved mood and enhanced cognitive performance are real. Many perceived benefits are actually attributable to the relief of nicotine withdrawal symptoms.

Although nicotine in the form of tobacco is a legal drug, it should not be regarded as pharmacologically benign. The classification of drugs as 'legal', 'soft' or 'hard' reflects public perceptions and current law enforcement practice, rather than constituting a useful pharmacological classification. In terms of addictiveness, nicotine delivered in tobacco smoke is a 'hard' drug on a par with heroin and cocaine. The status of nicotine as a seemingly innocuous legal drug, and attempts for many years by the tobacco industry to equate addiction to nicotine with addiction to substances such as coffee, colas or chocolate, have distracted attention from the highly addictive nature of nicotine in cigarettes.

9.2 Consequences of nicotine addiction

The principal adverse consequences of nicotine addiction are the morbidity and mortality caused by active and passive smoking. Nicotine addiction is the primary reason why smokers find it difficult to give up smoking. Most people begin smoking and become addicted to nicotine as teenagers. This addiction may then cause tobacco use to continue long after an informed adult choice has been made to stop smoking on the grounds of a change in attitude to health, changed circumstances such as starting work in a smoke-free office, starting a family or other reasons. This characteristic of tobacco use - an attenuation of free choice initiated in childhood - is a central plank of the case for government intervention to control tobacco use through measures such as advertising bans, tax increases, anti-smoking communications and cessation support, and to regulate the availability and safety of nicotine products.

Nicotine addiction is closely linked to socio-economic disadvantage. Smoking prevalence is higher and nicotine use heavier among poorer smokers. The socio-economic gradient in smoking behaviour accounts for about two-thirds of the excess premature mortality associated with deprivation. Nicotine addiction is therefore responsible for significant health inequalities.

The addictive properties of nicotine also mean that simplistic machine measurements of tar and nicotine yields from cigarettes do not reflect real tar and nicotine exposure to smokers. Smokers adjust the way they smoke in order to self-administer a satisfactory dose of nicotine - a process known as 'compensation'. In response to reduced nicotine concentration in smoke, a smoker can adjust nicotine intake back to a satisfactory level by smoking more intensely, holding smoke in the lungs for longer, smoking more of the cigarette, or by blocking ventilation holes in the filter. Cigarette testing machines do not adjust their inhalation profile in response to changes in nicotine. This criticism of cigarette testing is not a minor point; it completely undermines the approach currently used both for regulation of tar and for consumer labelling.

The phenomenon of nicotine 'compensation' has profound implications for the regulation, labelling and branding of cigarettes. The strategy of reducing nominal tar yields has been widely and genuinely assumed by governments and the European Commission to deliver reduced harm to smokers, since it is these other products of tobacco combustion, rather than nicotine itself, that account for most of the harm caused by smoking. The improved understanding of nicotine-seeking behaviour now suggests that this assumption cannot be sustained. The unfortunate truth is that cigarettes labelled as 'low tar' do not necessarily deliver less tar to the smoker. As a result, the official labelling of cigarettes with tar yields expressed as milligrams of tar per cigarette can mislead consumers, and in the case of 'low tar' cigarettes greatly understate the health risks compared to higher tar cigarettes. In the long term, this practice may be more harmful because it may help to perpetuate smoking in people who would otherwise give up completely for health reasons. The problem is further compounded by the use of branding terms such as 'light', 'mild', and 'ultra'. Though based on the government-sanctioned tar yields, such branding makes an implied health claim for low tar cigarettes that cannot be justified in practice.

9.3 Treatment of nicotine addiction

Over two-thirds of smokers say they would like to quit and about one-third try to quit in any year, yet only about 2% succeed. Many smokers will make repeated attempts, with a period of abstinence followed by relapse.
There are two main complementary forms of intervention to assist smoking cessation:

Motivation, support and advice.
Treatment products such as NRT.

The first is designed to increase smokers' commitment to stopping, the second to help attenuate cravings and withdrawal. For both, there are approaches with proven efficacy and attractive cost-effectiveness. The benefits of smoking cessation are substantial: immediate improved health, longer life, improved welfare and finances, and reduced passive smoking exposure to family, friends and working colleagues. At present, the NHS deploys a major part of its resources on the treatment of smoking related illness, but fails to provide widely available and accessible smoking cessation or prevention services.

9.4 Regulation of tobacco products

Tobacco products have enjoyed an unprecedented degree of freedom from the safety regulations that apply to virtually all other food or drug products available in Britain. Attempts to introduce regulations on the production, safety, promotion and almost all other aspects of tobacco products have been based predominantly on voluntary agreements with the tobacco industry, and have generally failed to deliver convincing public health benefits. All forms of NRT are required, quite properly, to meet the same standards of safety and product information as any other drug product, yet nicotine delivery products based on tobacco are largely exempt from such controls. It is now time to impose appropriate, effective and consistent safety regulations on all tobacco products in Britain.

9.5 Recommendations

We advocate a broad approach to tobacco control that deploys all the available policy levers consistent with upholding civil liberties and ensuring cost-effectiveness. In 1998, the UK government published an initial strategy to address tobacco use in the UK in the White Paper, Smoking kills,1 and we welcome and support all the practical initiatives proposed in that document. We recommend that this approach is augmented as follows:

In all areas of policy making and management of public health, nicotine delivered rapidly to the brain in tobacco smoke should be recognised as a powerfully addicting drug on a par with heroin and cocaine, and tobacco products should be recognised as nicotine delivery systems.
Tobacco product regulation is greatly complicated by the influence of nicotine on smoking behaviour. Current approaches to characterising the tar and nicotine yield of tobacco products are simplistic and misleading to consumers and regulators alike, and should be abandoned. This approach should be replaced
with measurements and metrics that properly reflect the relative harm caused by different tobacco products, and by measures to ensure that this information is appropriately provided to consumers.
Harm-reduction strategies based on naïve interpretation of tar and nicotine yield measurements should be discontinued. In practical terms, this means abandoning the strategy of seeking lower nominal tar yields and instead finding approaches that genuinely reduce harm to nicotine users. Branding such as 'light', 'mild' and other words or imagery that imply a reduced health risk attributable to low tar or nicotine measurements should be banned unless and until convincing evidence of reduced health risks is forthcoming.
The phenomenon of nicotine dependence is heavily entrenched in society. It is obviously desirable to reduce both nicotine dependence and the terrible harm caused by nicotine delivery through tobacco smoke, but it may be necessary to accept, albeit reluctantly, the intractability of widespread nicotine dependence in the short to medium term. In this case, product developments that enable nicotine users to take nicotine with less harm to their health should be encouraged, not rejected.
Warning labels on tobacco products should reflect their addictive nature.
Consideration should be given to the use of addiction messages in communication strategies aimed at young people, for whom a loss of control may be of more concern than a risk of cancer or heart disease much later in life.
Raising the price of tobacco products is well recognised to be an effective incentive to quit, and is thus an important preventive measure. However, taxation of addictive drugs also has an ethical dimension in terms of the financial deprivation that it can cause. It is therefore essential that government does everything possible to facilitate smoking cessation by providing universal access to evidence-based smoking cessation services.
Health communication programmes and smoking cessation services should be directed with particular emphasis towards those sectors of society in which smoking is most prevalent. These currently comprise the more disadvantaged sectors of British society. This orientation is essential if the pronounced health inequalities attributable to tobacco use are to be tackled.
Smoking cessation services should be made universally available at all levels in the NHS, and all doctors need to recognise nicotine addiction as a major medical priority. Primary care practitioners should regard it as a core function to treat nicotine addiction, just as they would wish to address alcohol dependence or illicit drug addiction. Hospitals and all other health service providers should be required to provide appropriate cessation support to all smokers.
NRT is a highly effective and cost-effective smoking cessation treatment, and will play a central role in tackling nicotine addiction. NRT should be available to all smokers through reimbursable NHS prescriptions, and also be widely available and affordable for general sale. NRT products are an essential and economic option for core NHS expenditure.
Smoking cessation services must adapt and be adapted, as appropriate, to incorporate new therapies and interventions that are shown to be effective and cost-effective.
The addicted condition of smokers in the workplace must be handled with sensitivity. Employers should be encouraged to provide support for smoking cessation, and to allow time for smokers to adjust to new conditions. It is also important for employers to minimise as far as they are able the risk of relapse among smokers attempting to overcome their nicotine addiction.
Cigarettes are nicotine delivery products, and should be subject to the same regulatory controls as any other drug delivery device.
Tobacco products in Britain should therefore be regulated either by the Medicines Control Agency or by a nicotine regulatory authority similar in concept to the Food Standards Agency.
We recommend 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.

Reference

Department of Health. Smoking kills. A White Paper on tobacco. London: The Stationery Office, 1998.

Contents

Contributors, Foreword and Key Points
1 Tobacco smoking in Britain: an overview
2 Physical and pharmacological effects of nicotine
3 Psychological effects of nicotine and smoking in man
4 Is nicotine a drug of addiction?
5 The natural history of smoking: the smoker's career
6 Regulation of nicotine intake for smokers, and implications for health
7 The management of nicotine addiction
8 Regulatory approaches to tobacco products in Britain
9 Summary and recommendations

This page last updated on May 4, 2001