Pubdate: Sat, 10 Nov 2001
Source: New Scientist (UK)
Copyright: New Scientist, RBI Limited 2001
Contact:  http://www.newscientist.com/
Details: http://www.mapinc.org/media/294
Page: 28-31
Author: Clare Wilson
Note: Clare Wilson is a medical journalist in London.
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)

MY FRIEND NICOTINE

Either Quite Or Die, Smokers Are Told. But Clare Wilson Says This Message 
Is Doing More Harm Than Good.

THE evil weed, cancer sticks, coffin nails ... From the names smokers use 
to describe their habit it's obvious they know they should quit. 
Politicians and doctors agree. The orthodox view is that slowly and surely, 
via creeping prohibition, tax hikes, education and medical intervention, 
people must be weaned off their deadly addiction until eventually, one fine 
day, the last smoker stubs out their last ciggy--and we'll all live happily 
ever after.

Fat chance. Smoking is on the up worldwide and the trend shows no signs of 
slowing. There's about a 1 per cent increase in cigarette consumption every 
year, with the number of smokers worldwide now standing at about 1.1 
billion and expected to rise to 1.6 billion by 2025. Small decreases in a 
few Western countries have been outweighed by people in developing nations 
taking up the habit with gusto. And even in much of the West, smoking among 
young people is rising, too.

The orthodox approach isn't working. Maybe it's time to think the 
unthinkable and accept that a tobacco-free world isn't going to happen. But 
learning to live with tobacco is not the same as leaving smokers to their 
fate. There are well-researched strategies to cut deaths from smoking that 
have little to do with propaganda or prohibition. They receive scant 
attention from governments because they're just not politically acceptable. 
But they work.

Take Sweden, for example. It was the only country to meet the World Health 
Organization's target of reducing smoking prevalence to 20 per cent of the 
population by 2000. Its success is all down to a strange cultural 
predilection for what might be called "sucking tobacco". No one's 
suggesting that the rest of us take up the habit, but Sweden points to a 
new way to save lives.

There's no doubt that smoking is a global health problem. Smokers are 25 
times as likely to contract lung cancer compared with non-smokers, and run 
two to three times the risk of a heart attack. Half of smokers die 
prematurely as a direct result of their habit, 4 million a year worldwide.

Yet smokers aren't dying of ignorance. They understand the harm their habit 
is doing to their health. According to British anti-smoking group ASH 
(Action on Smoking and Health), two-thirds of smokers want to quit and half 
of these attempt to do so every year. But success rates are dismal. Of 
those who try using will power alone, only 5 per cent are sticking to their 
guns one year later, according to a 1999 review by England and Wales's 
Health Education Authority.

The problem is that nicotine is ferociously addictive (New Scientist, 13 
August 1994, p 10). Once people get hooked, they find it nearly impossible 
to give up. Nicotine latches onto receptors in the brain, causing nerve 
cells to release the dopamine that produces a pleasurable high. This 
psychoactive effect makes users seek the drug outa classic element of 
addiction. In terms of chemical dependence, doctors rank nicotine as more 
powerful than heroin and cocaine.

The orthodox response has been to classify smoking as a "disease" and try 
to cure it. In the past few years drugs companies have flooded the market 
with "smoking cessation products". Almost all of these are nicotine 
replacement therapies--chewing gum, skin patches, lozenges or inhalers 
designed to deliver a dose of nicotine large enough to kill cravings but 
too small to produce a high. The idea is that you use nicotine replacement 
therapy as a temporary pharmaceutical crutch to keep the pangs at bay while 
you kick the habit.

Replacement therapy is possible because nicotine itself is pretty harmless. 
True, it does have some stimulatory effects on the nervous system, leading 
to raised blood pressure and heart rate. it's also toxic, though you'd have 
to chew 20 pieces of nicotine gum simultaneously to risk a lethal dose. 
Perhaps more seriously, nicotine itself is a mild carcinogen (New 
Scientist, 2 December 2000, p 10) and promotes blood vessel formation, 
which can help the growth of existing tumours. But the consensus is that 
smokers aren't dying from what they are actually addicted to. It's all the 
other chemicals in tobacco smoke that do them in.

Burning tobacco gives off around 4000 compounds, at least 60 of which are 
known to cause cancer. Cigarette smoke also contains carbon monoxide, which 
reduces the blood's ability to carry oxygen and so puts a strain on 
smokers' hearts and lungs.

Finding new ways of delivering nicotine satisfies short-term cravings, but 
its success rate in getting people to quit smoking isn't good. Without 
additional support, such as weekly counselling sessions and telephone 
helplines, 90 per cent of people who try nicotine replacement therapy start 
smoking again within a year. Even with the most successful drug, GlaxoS 
mith Kline's Zyban, around 85 per cent of quitters fail.

So how come Sweden does so well? The answer is that smokers there aren't 
faced with the quit-or-die dilemma. Instead of using a nicotine replacement 
therapy with the aim of quitting both smoking and ultimately nicotine, they 
can continue using tobacco as a recreational drug, safe in the knowledge 
that it probably won't kill them. It's all down to a product called "snus", 
a form of moist ground tobacco that you pop between your lip and gum. Snus 
comes in two forms, either loose or packed in small portions like miniature 
tea bags. Both deliver nicotine direct to the bloodstream.

Among Sweden's 3.4 million men, snus is more popular than smoking: about 19 
per cent use snus and 17 per cent smoke. That's easily the lowest rate of 
smoking in Europe-half the rate of Norway, for example-and it translates 
into an excellent health record. Swedish men have the lowest rate of lung 
cancer in Europe, according to WHO figures, and the lowest risk of dying 
from a smoking-related disease-just 11 per cent compared with 25 per cent 
in Europe as a whole. Karl Fagerstrom of the Helsingborg Smokers' 
Information Centre, a smoking cessation clinic, is in no doubt that snus 
should take the credit. "It's very hard to argue that there are other 
factors responsible," he says. "It's very common to switch from smoking to 
snus. If they can't give up smoking then I suggest snus because it's much 
less dangerous than setting fire to tobacco." Tellingly, about half of snus 
users are former smokers.

The evidence that snus improves public health becomes even stronger when 
you consider Swedish women. They hardly touch the stuff-only around 2 per 
cent use it-so act as a built-in control to the experiment. And their 
record on smoking-related diseases is nothing out of the ordinary. Swedish 
women are just as likely as any others to die from smoking, and their lung 
cancer rates are comparable with those of other Scandinavian countries.

Recreational drug

Snus isn't completely harmless. Users increase their risk of cardiovascular 
disease by 40 per cent. But that's lower than the risk among smokers. And 
crucially, snus doesn't seem to cause mouth cancer, which is a serious risk 
with other forms of oral tobacco. A long-term study of 135,000 Swedish men, 
published in the American Journal of Public Health in 1994, found that snus 
caused no increase in cancer risk at all. The reason is that snus is cured 
under conditions that inhibit the production of carcinogens.

Snus, in effect, is nicotine replacement without the therapy. It's a 
pleasurable, recreational drug, and users aren't under pressure to stop. 
Swedish Match, the Stockholmbased tobacco company that dominates the snus 
market in Sweden, explicitly promotes its product as a safer alternative to 
smoking.

The "Swedish experiment", as it has come to be known, has inspired some 
health campaigners to press for a more enlightened approach to the smoking 
epidemic. It's a concept they call "harm reduction". "If you look at 
Sweden, we have a living example of the concept in action," says Clive 
Bates, director of ASH.

Snus on its own will never be the answer. For one thing, few people outside 
Sweden have heard of it, though there's some tradition of use in Germany 
and Denmark. It's also illegal. The European Union banned it in 1992 as 
part of a general assault on oral tobacco. Sweden negotiated an opt-out 
when it joined the EU in 1995.

But the Swedish experiment does suggest that we could tackle smoking more 
creatively. In most countries, nicotine replacement therapies are tightly 
regulated, sold only in pharmacies as temporary aids for bona fide 
quitters. They're expensive-in the US, for example, one day's supply of 
nicotine replacement therapy can cost half as much again as a pack of 20 
cigarettesand product leaflets give strict warnings that using nicotine 
replacement therapy while still smoking could trigger a nicotine overdose, 
leading to dangerous heart problems. In other words, if you want to use 
replacement therapy to help you cut down, whittle down a 40-a-day habit in 
stages, or just get through a non-smoking transatlantic flight, you're in 
for an uphill struggle.

To many anti-smoking activists this is crazy. David Sweanor, legal adviser 
to the Canadian Smoking and Health Action Foundation, cites the example of 
a parent on a long car journey, desperate to avoid smoking as their child 
is in the back seat: "Cigarettes are readily available at their first 
petrol stop, but nicotine gum isn't." He believes that as well as being an 
aid to quitting, nicotine replacement therapies should be available as a 
consumer product.

But drug regulatory agencies are ultracautious. They're not convinced by 
the argument that chewing nicotine gum for half your life can't be as bad 
as smoking like a chimney, because it hasn't been tested in long-term 
clinical trials. "Going from a pack a day to half a pack a day is bound to 
make a difference to People's health," Sweanor says. "But until you can 
prove that, you can't get that licence."

Harm reduction, however, isn't the sole preserve of the drugs industry. 
Some tobacco companies have decided to take the matter into their own hands 
by developing safer cigarettes. Admittedly, they'll still probably shorten 
smokers' lives, but maybe by not quite as much-which must be better than 
leaving things as they are.

One safer cigarette currently being testmarketed is Eclipse, developed by 
US tobacco giant RJ Reynolds. It consists of a tube of tobacco with a heat 
source at one end. To "smoke" it you light the heat source and suck on the 
other end, which draws heated air through the tobacco and evaporates the 
nicotine in a similar way to hot water passing through coffee grounds (see 
Diagram, left). Most of the tobacco doesn't catch fire and the cigarette 
doesn't burn down. RJ Reynolds claims that the smoke contains lower levels 
of 14 known or suspected carcinogens than ordinary cigarette smoke.

RJ Reynolds test-marketed a similar product, Premier, in 1988 but withdrew 
it because smokers didn't like the taste. Eclipse has a shot of tobacco in 
the heat source to produce a slug of real smoke, but it's still not certain 
that smokers will take to it.

Other tobacco companies are trying to make actual cigarette smoke safer, by 
reducing levels of carcinogens. One American firm, Star Scientific, is 
staking its future on a tobacco-curing process that it says reduces the 
levels of some carcinogens.

But again, there are regulatory problems. There's no point in tobacco firms 
investing money in safer products if they are not allowed to make health 
claims. And regulators take a dim view of using the words "safe" and 
"cigarettes" in the same sentence.

They've had their fingers burnt, so to speak, on this before, by low-tar 
cigarettes. Regulators were happy to accept health claims, only to find 
that "light" brands were actually more dangerous. Low-tar smoke is less 
irritable to the airways, so smokers inhale more deeply, exposing a greater 
proportion of their lung tissue to carcinogens. As a result, lung cancer 
rates actually rose after the introduction of low-tar cigarettes (New 
Scientist, 15 March 1997, p 8).

Despite the regulatory problems, there are signs that health authorities 
are starting to take harm reduction seriously. Earlier this year, the US 
Institute of Medicine published a report on "potential reduced-exposure 
products", including snus and nicotine replacement therapy. The key 
question was whether harm-reduction products save lives in the long run, or 
whether their benefits are outweighed by people staying addicted to 
nicotine when they might otherwise have quit-or even taking up smoking when 
they wouldn't have otherwise.

Backward step

The report was eagerly awaited by harm reduction advocates who hoped it 
would back their way of thinking. But they were disappointed. One of the 
main conclusions was that there's no evidence harm reduction improves 
public health, and might even damage it. Far from breaking new ground in 
tobacco policy, the report was widely seen by campaigners as a retrograde step.

joint author Robert Wallace, an epidemiologist at the University of Iowa, 
defends the report, saying: "We don't want people to be misled into 
thinking they are taking a product that's less harmful to their health when 
what they should be doing is quitting. The long-term health effects of 
these products are not defined. They certainly should not be able to make 
claims that they're safer because there's simply no evidence."

Outside the US, however, harm reductionists are gaining ground. New 
legislation in the EU will soften the health warnings on sous, replacing 
"causes cancer" and "seriously damages health" with "can damage your 
health" and "is addictive". The same legislation, due to come into force 
next year, enjoins EU scientists to investigate reducedrisk tobacco 
products. Whether this will pave the way for snus to be legalised across 
the EU remains to be seen, But a showdown is likely when Swedish Match 
takes the German authorities to the European Court of Justice for trying to 
enforce the ban.

The WHO has gone even further. Its most recent report on regulating tobacco 
products, published in May, acknowledges that there is a need for new 
tobacco delivery systems, and even calls for "more progressive" regulatory 
methods.

No one sensible is suggesting that harm reduction should replace measures 
such as banning tobacco adverts or sales to children. And the single most 
beneficial thing an individual smoker can do is quit. But there might be 
real public health benefits from pursuing policies that encourage harm 
reduction when quitting isn't possible.

There are historical precedents. Needle-exchange schemes for heroin addicts 
sparked moral outrage when they were first introduced, but they are now 
seen as an invaluable tool in reducing the spread of HIV and hepatitis. 
Harm reduction for nico-tine addicts also entails steps that some view as 
morally repugnant. Legislators and doc-tors will have to start working 
side-by-side with tobacco companies, having spent all their professional 
lives viewing them as agents of Satan. Perhaps they're taking the term 
"evil weed" too literally.
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MAP posted-by: GD