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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 21-July-2006, Vol 119 No 1238

Where to next with tobacco smokers?
Ross McCormick, Doug Sellman, Geoff Robinson
Just under 25% of New Zealanders smoke tobacco cigarettes,1 which is virtually the same as in the United States, but significantly higher than Australia (20%).2 However the New Zealand statistic includes a 50% prevalence rate of smoking amongst Māori and 30% for Pacific people (most of whom are of Samoan, Tongan, Niuean, or Cook Islands descent).1
It is nearly 20 years since the United States Surgeon General report made strong, unequivocal statements about the nature of nicotine addiction in the form of two major conclusions:
  • “Cigarettes and other forms of tobacco are addicting”; and
  • “Nicotine is the drug in tobacco that causes addiction”.3
These conclusions have been more recently reiterated in a special 2000 Report of the Royal College of Physicians, the central conclusion of which was; “Cigarette smoking should be understood as a manifestation of nicotine addiction, and the extent to which smokers are addicted to nicotine is comparable with addiction to ‘hard’ drugs such as heroin or cocaine”.4 Their Report comments that about two-thirds of smokers say they would like to quit and about one-third try to quit in any 1 year, yet only about 2% succeed.
In New Zealand, considerable efforts have been made to reduce smoking prevalence. The approaches used have been public health focussed, using a broad range of methods including education campaigns, warning labels, legal restrictions on where people can smoke tobacco, taxation on cigarettes, and Quit Lines (with free access to nicotine substitution for 8 weeks to help overcome nicotine withdrawal symptoms).
However, despite these approaches producing admirable success over the years, how much further can a purely public health approach go? As prevalence now slowly decreases, it is probable that the remaining smokers are the more severely addicted ones and this may make further reductions in prevalence difficult. Indeed, the remaining highly dependent smokers are likely to need more intensive treatment.5
What can be learnt from the experience with other drugs of addiction, such as opioids? In New Zealand, the strategy to reduce harm due to opioid dependence includes supply control, demand control, and problem limitation.6 For instance, supply control includes legal restrictions, and demand control includes education campaigns. Problem limitation involves a variety of objectives. Some services aim to assist an addicted person to become abstinent from opioids, others aim to reduce harmful administration of opioids by supplying clean needles, and still others aim to normalise the opioid dependent person’s life by prescribing oral substitutes such as methadone.
There are a variety of professionals involved in helping the dependent opioid user including general practitioners, pharmacists, addiction specialists, nurses, psychologists, recovering addicts, and counsellors.
Like opioids, nicotine is rewarding and addictive. Nicotine’s relaxation effect, improved mood effect, and improved cognitive performance effect are greatest when the nicotine is delivered rapidly to the brain through inhaled smoke or through other rapid high-dose delivery systems.7 However, there are well-known dangers of rapid opioid self-injecting delivery systems (e.g. hepatitis C infection), and similarly there are well-known dangers of rapid nicotine smoking delivery systems (e.g. severe lung disease) where the risks are mostly due to some of the 4000 or so chemicals in cigarette smoke other than nicotine.4
Both opioids and nicotine are highly addictive drugs, yet their ongoing use is compatible with a relatively normal life: it is the delivery system that causes the most harm.
In New Zealand, there are no services offering problem limitation services for tobacco addiction analogous to those offered opioid addicts. The goal of most existing tobacco dependence treatment services is abstinence from nicotine, achieved through quitting cigarette smoking. Tobacco addiction treatment remains locked in a 1970s opioid addiction service model of sequential abstinence and relapse, often many times over.
A harm minimisation approach to tobacco addiction would argue that substitution drug treatment, such as Swedish snuff, should be an option for longer periods than 8 weeks; possibly indefinitely. People would remain dependent on nicotine, but their ongoing use of nicotine would have far reduced risk of harm compared with smoking tobacco cigarettes.
Products such as Swedish snuff are themselves not thought to be risk-free,8 but then neither are clean needles and oral methadone for opioid-addicted people. However, the risks appear to be significantly less than those of smoked tobacco, and that alone would justify trialling their use.
We consider it is time for a paradigm shift in the way the harm due to tobacco in New Zealand is approached. This paradigm shift is needed by policymakers, researchers, and health services.
Policymakers need to talk with tobacco companies to encourage them to shift to smokeless tobacco products with increased safety profile compared to smoked cigarettes. Furthermore, researchers need to be funded for projects that will evaluate the risks and benefits of harm minimisation approaches such as substitution of cigarettes by rapid-acting non-inhaled high blood level nicotine products.
Māori researchers and policy makers are best placed to ensure any proposed changes meet the needs of Māori. There needs to be public debate about the best sales system: direct sales to the public, monitored sales through pharmacists, or prescription.
Finally, the medical profession needs to debate this issue widely to help develop the best harm-minimisation approaches for the increasingly hard-core group of nicotine-addicted people.
Author information: Ross McCormick, Director, Goodfellow Unit, University of Auckland and Chair of New Zealand Section of the Chapter of Addiction Medicine, RACP, Auckland; Doug Sellman, Director, National Addiction Centre, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch; Geoff Robinson, Consultant Physician, Alcohol and Drug Services, Capital and Coast DHB, Wellington
Correspondence: Professor Ross McCormick, Goodfellow Unit, School of Population Health, University of Auckland, Private Bag, Auckland. Email: r.mccormick@auckland.ac.nz
References:
  1. Ministry of Health. Tobacco facts 2005: adult smoking survey. Wellington: Ministry of Health; 2005.
  2. White V, Hill D, Siahpush M, Bobevski I. How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001. Tob Control. 2003;12(Suppl 2):67–74.
  3. Surgeon General Report. The health consequences of smoking: nicotine addiction. Washington DC: US Department of Health and Human Services, Centres for Disease Control; 1988.
  4. Royal College of Physicians. Nicotine addiction in Britain. London: Royal College of Physicians; 2000.
  5. Fagerstrom KO, Kunze M, Schoberberger R, et al. Nicotine dependence versus smoking prevalence: comparisons among countries and categories of smokers. Tob Control. 1996;5:52–6.
  6. Ministry of Health. National drug policy 2006-2011 consultation document. Wellington: Ministry of Health; 2006.
  7. Jones RT, Benowitz NL. Therapeutics for nicotine addiction (chapter 107). In Davis KL, Charney D, Coyle JT, Nemeroff C (eds). Neuropsychopharmacology: The Fifth Generation of Progress. American College of Neuropsychopharmacology; 2002.
  8. Bolinder G. Swedish snuff: a hazardous experiment when interpreting scientific data into public health ethics [comment]. Addiction. 2003;98:1201–4; discussion 4–7.
     
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