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.