Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A question
- Anastacia M Shimek (14 February 2000)
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write it as it is
- Stephen Workman (16 February 2000)
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More about nicotine.
- Tom Oommen (16 February 2000)
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Availability of nicotine replacement therapy
- John Britton (21 February 2000)
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The situation in Pakistan
- Masood Ali Shaikh (24 February 2000)
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Cigarettes should be banned
- Gabriel Symonds (7 March 2000)
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Health and medical organisations' letter to Secretary of State on nicotine addiction and treatment
- Clive Bates (15 March 2000)
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NRT on prescription
- Godfrey Fowler (17 March 2000)
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Anastacia M Shimek, N/A N/A
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In this editorial, Professor Moxham makes the statement: "Nicotine replacement therapy would develop many of the crucial attributes of cigarettes, . . ." I am interested to know what the above phrase refers to, i.e., should the NRT to which you refer that would develop many of the crutical attributes of cigarettes, be like cigarettes in that the NRT would be in the form of a cigarette-like device, to administer decreasing doses of nicotine while providing a key behavioral component of smoking -- the hand -to-mouth ritual? Thank you. Anastacia M. Shimek |
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Stephen Workman, Assistant Professor Dalhousie University
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An 'admitting diagnosis' is part of every properly done history and physical. For patients who are continuing to smoke despite the development smoking related diseases 'nicotine addiction' should be the admitting diagnosis. It never is. |
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Tom Oommen, Associate Profesor of Pharmacology Fr. Muller's Medical College, Mangalore, India
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Nicotine was first isolated from tobacco smoke in 1809 by Vanquelin, and its chemical nature was established in 1829. the substance was named after James Nicot, a French Ambassador in the mid-sixteenth century, who brought the plant from Florida and planted it in Portugal, where it grew abundantly and was used for the treatment of skin disorders. In our culture where there is a pill for every ill psychotomimetic drugs have become a symbol of prestige, success, happiness and relaxation. According the the WHO, drug addiction is a psychic or physical stage resulting from the interaction between a living organism and a drug, and characterised by behavioral and other responses that always include a compulsive desire to experience its effect and /or avoid discomfort of its absence. Dependance is also defined as a state of periodic or chronic intoxication detremental to the individual and to society, produced by the repeated use or consumption of substances. This is also true of the nicotine addict (1). Amongst the neurochemical systems which have been examined, most emphasis has been given to dopamine. The mesolimbic dopaminergic pathway has been implicated in nicotine reward based on animal studies. Research on human subjects suggests a role of for dopaminergic processes as well. Dopaminergic blockade appears to increase cigarette smoking behavior in humans. Animal studies allow for the analysis of anatomical and physiological mechanisms underlying nicotinic self-administration; human studies validate the relevance to tobacco-dependance and smoking cessation treatment (2). Tobacco smoking is reinforced by nicotine intake. It is also accepted that smoking increases free radical products within the body. According to the University of Massachussetts doctors who found radioactive isotopes, particularly of Polonium (Po-210) from the phosphate fertilisers used in growing tobacco, and lead (Pb 210) which is highly concentrated in tobacco particles, a pack -a-day smoker can absorb as much ionising radiation in a year as he would were he to have 200 chest x-rays. It has also been suggested that prenatal exposure to tobacco evokes delayed neurotoxicity by altering the programme of neural cell differentiation, and an elevation of c-fos proto oncogene expression provides an early marker of the eventual defects (3). Smokers can reverse damage by giving up the habit. Within a year of giving up the habit the risk of coronary artery related morbidity becomes almost equal between smokers and non-smokers. There is absolutely no therapeutic role of tobacco, though nicotine has found a limited use as an insecticide. The global pressure against the manufacture and sale of nicotine-containing substances should be increased, specially after reports which claim that cigarette smoking remains the single largest cause of premature disability and death in the UK (4). A classical example of both the fool and his money going up in smoke! References: 1. Moxham J. Nicotine addiction. BMJ 2000; 320: 391-92 2. Rose JE & Corrigal WA. Nicotine self-administration in animals and humans: similarities and differences. Psychopharmacol. 1997; 30 (1): 28-40 3. Slotkin TA et al. Cryptic brain cell injury caused by fetal nicotine exposure is associated with persistent elevation of c-fos proto oncogene expresion. Brain Res. 1997; 750 (1): 180-188 4. Kmietwicz Z. Doctors told to treat nicotine addiction as a disease. BMJ 2000; 320: 397 |
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John Britton
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Sir, Professor Moxham [1] and the recent Royal College of Physicians report [2] draw attention to the need for nicotine replacement therapy (NRT) to be made generally available on prescription in the UK. NRT is a cost- effective therapy [3,4] that saves lives, and saves money by reducing the estimated £1.5 billion burden of smoking related disease currently met by the NHS [2]. It now transpires that as a result of a regulatory loophole, a limited number of NRT products that have been licensed relatively recently but not yet removed from the list of drugs available for NHS prescription can in fact be prescribed at present. These products include the NiQuitin CQ transdermal patch, the Nicorette Microtab, Nicorette inhalator and Nicotinell lozenge, and possibly some others. For the time being therefore, and until such time as they are removed from the list of medicines for which reimbursable prescriptions can be issued, it would appear that these products can be prescribed by UK general practitioners in the same way as any other drug. John Britton
References 1. Moxham, J. Nicotine addiction. BMJ 2000;320:391-2 2. Tobacco Advisory Group, Royal College of Physicians. Nicotine addiction in Britain. London: RCP,2000 3. Raw, M., McNeill, A., and West, R. J. Smoking cessation guidelines for health care professionals. Thorax 1998;53 (Suppl 5 Part 1):S1-S19 4. Parrott, S., Godfrey, C., Raw, M., West, R., and McNeill, A. Guidance for commissioners on the cost-effectiveness of smoking cessation interventions. Thorax 1998;53 (Suppl 5 Part 2):S1-S38 |
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Masood Ali Shaikh
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Dear Sir, Your Feb 12(1) editorial suggested that warnings on cigarette packets should emphasize the addictive nature of smoking. In developing countries like Pakistan, where the all mighty multinational cigarette companies are aggressively marketing their lethal product with a new rigor, combating cigarette manufacturers has never been be easy. In spite of the stated objectives of the Pakistan's health policy, the smoking prevalence rate is 21.6%, documented in a nation-wide survey(2). In Pakistan, 10% of government revenue is generated from taxing cigarette manufacturers and over 30% of state television advertising revenue is generated from cigarette manufacturers. Targeting public cigarette advertising and convincing policymakers to limit or altogether ban the same, is a long, hard and costly battle. As the World Health Organization(3) (WHO) is looking for allies, in its efforts to counter the counter-productive effects of World Trade Organization's practices on global public health it may find an ally in the World Court of Justice. The cigarette manufacturers knew all along about the hazardous and addicting nature of their product, yet deliberately chose not to inform the consumers, which clearly constitutes criminal negligence. The WHO, on behalf of the citizens of the planet, may file a suit against them in the World Court of Justice. Something akin to Nuremberg trials might evolve and, a victory similar to the one in Minnesota could await. That will save lot of global efforts and resources in combating the menace of tobacco , through traditional public health measures, and presumably much sooner too. And after Smallpox, "eradication" of another disease would become a reality, with profound reduction in the global burden of diseases attributed to cigarette smoking. My only concern is that some lawyers will become filthy rich along the way, but that is the price world can live with. (1) Moxham J. Nicotine addiction. BMJ 2000; 320:391-2 (2) Alam SE. Prevalence and pattern of smoking in Pakistan. J Pak Med Assoc 1998; 48:64-66. (3) Aventin L. Trade agreements and public health: role of WHO. Lancet 2000; 355: 580 Competing Interests: NONE Masood Ali Shaikh
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Gabriel Symonds
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Dear Sir - Although the recognition that nicotine addiction is the central problem of smoking is to be welcomed, it does not follow, as Professor John Moxham claims (12 February, p 391), that "nicotine replacment therapy is a rational and indeed effective therapy". If the idea is to rid the body of nicotine, what is the point of changing the route of administration, from absorption through the lungs to absorption through the skin or buccal mucosa? Professor Moxham also calls for "urgent and substantial research and development; for "much more effective" forms of nicotine replacment therapy which would "become a real rival to cigarettes." Does he really wish to see millions of people using such improved nicotine delivery devices as a substitute for cigarettes? The only action that needs to follow the recognition of the addictive nature of smoking, is for cigarettes to be placed in the same legal category as heroin and cocaine, and be banned. Gabriel Symonds, MB BS
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Clive Bates, Director Action on Smoking and Health
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The following letter puts many of the issues raised in the editorial to the Secretary of State for Health. We are awaiting his response. From: Royal College of Physicians, Cancer Research Campaign Imperial Cancer Research Fund, British Medical Association,Faculty of Public Health Medicine, National Heart Forum, Action on Smoking and Health. Rt Hon Alan Milburn MP
1st March 2000 Dear Alan Prescription of Nicotine Replacement Therapy As you know, the College recently published a book ‘Nicotine Addiction in Britain’, which included a wide range of policy recommendations in relation to nicotine regulation, smoking cessation, and branding and labelling of cigarettes. The College will be pursuing all of these recommendations in due course, but the most pressing of these is the issue of nicotine replacement therapy and other proven treatments for nicotine addiction. The report recommends that since NRT is a highly effective and cost- effective smoking cessation treatment, it should be available to all smokers through reimbursable NHS prescriptions, and also be widely available and affordable for general sale. At present this is not the case, as the provision of one-week’s free NRT to low-income smokers is concentrated through the specialist services in Health Action Zones, though soon to be extended to all health authorities. GPs can currently prescribe recently-introduced NRT products which have not been withdrawn from prescription through the ‘blacklisting’ procedure, such as NiQuitin CQ and Nicorette Microtabs to patients as they see fit. This rather arbitrary availability of NRT on prescription is unsatisfactory and clearly requires an urgent resolution. It would seem irrational to blacklist products that are acknowledged in NHS guidance to be cost-effective, could engage GPs in smoking cessation and help achieve targets for smoking prevalence, cancer and heart disease. Given the limited throughput of the specialist smoking cessation services in Health Action Zones so far, there is almost no chance of the NHS reaching those targets without much broader engagement of the NHS. The signatories to this letter believe that the only way to get close to the targets is to remove the restrictions on prescribing NRT products, and make smoking cessation a core function of the NHS, by supplying resources and funding. This is, in fact, more cost-effective in CHD prevention than using statins for cholesterol lowering. We understand the Government’s concerns about the cost of prescribing NRT, but since the Chancellor has already announced that additional tobacco taxation revenues will be allocated to the NHS, some of these proceeds could be used to establish a world-class smoking cessation regime. The College report shows that nicotine is a powerfully addictive drug on a par with hard drugs such as heroin and cocaine - proven and cost- effective treatments for this most pervasive of drugs should be widely available and routinely prescribed at all levels of the NHS. There are no other measures which would benefit the health of the population more, and as Secretary of State for Health, we urge you to acknowledge this as a priority. Yours sincerely George Alberti
Gordon McVie
John Toy
Ian Bogle
Jim McEwen
Sir Alexander Macara
Clive Bates
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Godfrey Fowler
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Editor - In his Editorial (Nicotine Addiction,12 Feb.), John Moxham calls for availability of nicotine replacement therapy (NRT) on NHS prescription. The arguments for this were pointed out (Smeeth L,Fowler G Nicotine replacement therapy for a healthier nation.Editorial BMJ 1998:317;1266-7) at the time of publication of 'Smoking Kills'. But, in spite of all the evidence of effectiveness and cost-benefit of cessation advice and NRT in general practice, we got the nonsense of a week's free supply for 'poor smokers' only in virtually non-existent and unproven 'specialist smoking cessation clinics'. Predictably, establisment of such clinics and smoker recruitment have proved problematic. With almost a quarter of a million smokers every day seeing GPs and practices nurses, general practice is where most advice and help to stop smoking is,and always will be, delivered - especially for the socially disadvantaged who are rightly the priority target. Denying GPs effective interventions is a major barrier to their engagement and effectiveness. The likely UK licensing of bupropion for smoking cessation within the next few months will further highlight this issue, so its resolution is now urgent. Godfrey Fowler |
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