|
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
|
