Category Archives: nicotine replacement

Big Tobacco bashing

Tobacco company CEOs lying to the US Congress in 1994 that nicotine is not addictive

For today’s post, let’s hear it from the Tobacco Action Committee of the American Thoracic Society (ATS).

The Committee is charged with organizing and coordinating the [Society’s] tobacco control activities [which] will include…activities with the ultimate goal of minimizing the impact of tobacco on morbidity and mortality worldwide. The committee will strive to enhance the ability of the ATS to participate more fully in the investigation of the root causes of tobacco use; treatment of nicotine dependence; and advocacy efforts to eliminate its use… (Emphasis added.)

First they say their ‘ultimate goal’ (the word ‘ultimate’ is redundant’) is to minimize the impact of tobacco on morbidity and mortality (illness and death). And by the way, do they want to participate more, or participate fully, in the investigations?

Then, as they verbosely put it, (paraphrasing slightly) they will ‘strive to enhance the ability to participate in advocacy to eliminate tobacco use’. Perhaps they mean to say, ‘The committee will investigate the cause of tobacco use and strive to eliminate it.’

So what do they want to do: minimize the effects of tobacco or eliminate its use?

Even so, it’s unclear how ‘treatment of nicotine dependence’ fits in here. If tobacco use is eliminated then the treatment of nicotine dependence will take care of itself. The carelessness of the copywriter is also shown by the plural use of ‘root cause’. The root cause of something means the fundamental reason for the occurrence of a problem, so by definition there is only one.

This uncertainty about what they are trying to achieve is also reflected in the widely reported comment of Dr Harold Farber, Chair of the ATS Tobacco Action Committee, to the news that on 26 November 2017 the Tobacco Industry (sic) has to make ‘corrective statements’ in the US media of the following kind:

  • Smoking kills, on average, 1,200 Americans every day.
  • More people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol, combined.
  • Smoking causes heart disease, emphysema, acute myeloid leukemia, and cancer of the mouth, esophagus, larynx, lung, stomach, kidney, bladder, and pancreas.
  • Smoking also causes reduced fertility, low birth weight in newborns, and cancer of the cervix.
  • Smoking is highly addictive. Nicotine is the addictive drug in toacco.
  • Cigarette companies intentionally designed cigarettes with enough nicotine to create and sustain addiction.
  • It’s not easy to quit.
  • When you smoke the nicotine actually changes the brain – that’s why quitting is so hard.
  • Etc.

Dr Farber: ‘This is the first time tobacco companies are acknowledging the truth to the general public: tobacco is a product that is hightly addictive and as a direct consequence of its design, kills people when used exactly as intended.’

Give him a big hand for pointing out the obvious.

The origin of this dates back to 2006 when the US District Court of Columbia found that several major cigarette manufacturers were guilty of racketeering and misleading the public; publication of these statements was part of the punishment imposed on them.

The cigarette companies resisted this measure because, as they not unreasonably pointed out, they didn’t want to have to brand themselves as liars – even though they are.

Apart from that, what is point of publishing these statements? Is it to treat Big Tobacco  like a naughty school child being made to write out a hundred lines? Is it to tell the public stuff they don’t know? Is it to try to make smokers quit throught fear? (I would disagree with the statement that it’s not easy to quit.) One may speculate on all this but I think it misses the point.

How about calling for the US government to be brought to account for knowingly allowing a product to be sold which:

  • Kills, on average, 1,200 Americans every day – more than die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol, combined.
  • Causes heart disease, emphysema, acute myeloid leukemia, and cancer of the mouth, esophagus, larynx, lung, stomach, kidney, bladder, and pancreas.
  • Also causes reduced fertility, low birth weight in newborns, and cancer of the cervix.
  • Etc.

Further, I would seek to force the government to issue a corrective statement that it failed in its duty to protect the public by leaving it up to the consciences of those decent people who run tobacco companies to put themselves out of business.

Text © Gabriel Symonds

Can’t see the wood for the trees – or the nicotine for the e-cigarettes?

A headline in today’s online BBC news (so it must be true) announces ‘E-cigarettes: Cross-party group of MPs launches inquiry’.

The main point of this exercise is to try and fill the ‘significant gaps’ in what is known about e-cigarettes including how effective they are as a stop smoking tool and how they are (or should be) regulated. But it’s curious that these ideas are put forward as a reason for an inquiry – because what is already known about e-cigarettes together with what can be reasonably surmised is enough to make such an inquiry unnecessary.

E-cigarettes should first of all be seen, not as a stop smoking tool, but for what they are: a supposedly safer way for smokers to continue their nicotine addiction.

There are almost three million vapers in the UK and about half of them smoke as well. In other words, for these people vaping is an alternative or additional means of taking nicotine into their bodies. But why is it assumed, for smokers concerned about the dangers of smoking, that an alternative is needed at all? Recommending e-cigarettes is becoming almost a knee-jerk response for those seeking help to stop smoking.

The enquiry might better look into these questions: Why do people smoke? Why does it seem so hard to stop? Do smokers really want to stop anyway, and if not, why not? Is it or should it be public policy that millions of vapers in the UK are in the thrall of long-term nicotine addiction?

E-cigarettes are supposed to be safer than smoking, but it’s patronising and almost insulting   to encourage smokers to use them. It amounts to saying, ‘There, there, you poor smokers, it’s too hard for you to quit. But never mind, you can carry on being addicted to nicotine in a way that we hope will be less damaging to your health!’

Now, suppose we could anticipate the result of our cross-party group of MPs’ inquiry over the next few years or decades (because this is how long it will take for a definitive answer  into the health effects of e-cigarettes) and that this will be: vaping is completely harmless! That is to say, it will be found that e-cigarette vapour, which consists of nicotine, water, flavourings, propylene glycol and glycerin, as well as trace amounts of cancer-causing chemicals and heavy metals, even when inhaled into the lungs many times daily for years on end, poses no danger whatsoever to the vaper or those around him or her including babies, children and pets.

Further, let’s anticipate that the originators of the slogan ‘E-cigarettes are 95% safer that smoking’ were over-cautious in arriving at this figure and now it can be said with complete certainty that e-cigarettes are 100% safer than smoking!

These statements of course are fantasies. But let us assume for the sake of argument that these conclusions are true. Therefore, if e-cigarettes are to be promoted as a stop-smoking tool, putting aside the question of whether they should be allowed at all, then it follows that since ordinary cigarettes are certainly not safe (they kill around half of all smokers) the action that needs to be taken on public health grounds is obviously to ban ordinary cigarettes at once.

And if we further suppose for the sake of argument that the results of future research will show that e-cigarettes are, indeed, 95% safer than ordinary cigarettes, or that they are, say, only 50% safer, then the argument to abolish ordinary cigarettes forthwith still would apply.

Even to a sceptic such as I it’s unlikely that e-cigarettes will turn out to be equally or more dangerous to users’ health than ordinary cigarettes – but they could be. See my post on ‘vaper’s lung’ (http://nicotinemonkey.com/?p=1406).

Now let’s consider the second reason why our parliamentary representatives feel the need for an inquiry into e-cigarettes: how they are regulated.

Current regulations limit the concentration of nicotine in the e-liquid, the size of the refills and the requirement that a label must be affixed to the product warning purchasers it contains nicotine which is highly addictive. So far so good, or bad, but in addition, in the UK only people over 18 years of age are permitted to buy e-cigarettes. However, just as with ordinary cigarettes, that won’t stop any enterprising youngster who wants to vape from obtaining the kit and doing so – indeed, it’s a serious problem that so many children vape and smoke and thereby become addicted at a vulnerable age and go on to become regular users of nicotine. So, regulation with the intention of preventing people under 18 from vaping or smoking or both, is largely ineffective. With this in mind, it’s relevant to ask how does our group of parliamentarians anticipate changing or tightening the regulations, and why?

There’s a much more effective way of stopping smoking than turning to other nicotine products. It needs to be remembered that smoking is largely a psychological problem. This was recognised in the US as long ago as 1964 in the seminal Report of the Surgeon General on The Health Consequences of Smoking:

The overwhelming evidence points to the conclusion that smoking—its beginning, habituation, and occasional discontinuation—is to a large extent psychologically and socially determined.

How to use this knowledge to achieve simple smoking cessation has been set out in my books, available the publisher and Amazon.

Text © Gabriel Symonds

How to be popular

I quote from British American Tobacco’s International Marketing Principles, 2015:

We will not portray smoking as an activity that makes people appear more popular,appealing or successful.

But they seem to have no qualms about portraying the use of their new product with the almost unpronounceable name of ‘glo’ as an activity that makes people appear more popular, appealing or successful.

This is from a twenty-four page booklet about ‘glo’ in Japan. I picked it up from promotional display in the street outside a corner shop selling cigarettes. A young person seeing this – and how can you prevent children and young people from seeing this and similar advertising? – might well want to try it just to appear popular and appealing like the models in the picture. While all of them except one are raising their glasses in a toast to something, three of the models are looking directly at the exception, the young man holding, not a glass of wine, but his ‘glo’ contraption. Also, note the bowl of fruit in the lower part of the picture – healthy food – being associated with the poison you can suck into your lungs with the ‘glo’ thingummy.  The advertising people must have worked really hard on this one!

 So I wrote to BAT through their website asking them the following question:

In your International Marketing Principles you say, ‘We will not portray smoking as an activity that makes people appear more popular,appealing or successful.’ But your promotional leaflet and the website for ‘glo’ in Japan does just this very thing. Do you have different ethical standards and marketing principles in different countries?

I received a polite reply from someone in their External Affairs department in Japan:

Although we don’t have specific International Marketing Principles in place for Tobacco Heating Products yet, please be assured we are applying the spirit of our existing principles to ‘glo’ as well as adhering to all regulations and voluntary codes.

I shall leave it to the reader to judge how far the spirit of BAT’s existing principles applies to to  their ‘glo’ product.

And how about this display in a Tokyo convenience store, conveniently placed at a child’s eye level:Big Tobacco, fearing that sales of cigarettes are going to decline more and more (at least in most developed countries), are rushing to bring out alternative tobacco products with the claim that these are less harmful. Apart from BAT’s ‘glo’, examples are Philip Morris’s IQOs (or iQOS) and Japan Tobacco International’s  ‘Ploom’ – at least you can pronounce the last-mentioned.

The fumes generated by these products still contain poisons, although maybe in smaller amounts compared with ordinary cancer sticks. The user is going to suck the fumes thereof into his or her lungs many times a day for years on end. And for what? To achieve a state of bliss? To see visions of heaven?

Are we non-nicotine users missing something?

Text © Gabriel Symonds

Why nearly all stop smoking websites are unhelpful

I put ‘How to stop smoking’ in Google and this is what came up (emphases added) :

Readers’ Digest

The 23 Best Ways to Quit Smoking…Make an honest list of all the things you like about smoking…Then make another list of why quitting won’t be easy.

WebMD

So you’re ready to kick the habit. That’s great! Making that commitment is half the battle. It’s not going to be easy. But choosing the best way to quit is a good first step to ensure you stick with it

wikiHow

Nicotine is incredibly addictive and it will take determination to quit….Be prepared for nicotine-withdrawal symptoms…When you stop smoking, you might experience increased cravings, anxiety, depression, headaches, feeling tense or restless, increased appetite and weight gain, and problems concentrating….

helpguide.org

We all know the health risks of smoking, but that doesn’t make it any easier to kick the habit…quitting can be really tough.

kidshealth.org

…it’s true that for most people quitting isn’t easy…Everyone knows it can be hard to stop smoking..the nicotine in cigarettes is a powerfully addictive drug…You’ll need patience and, yes, willpower.

Mayo Clinic

10 ways to resist tobacco cravings…Tobacco cravings can wear you down when you’re trying to quit…tobacco cravings or urges to smoke can be powerful… when a tobacco craving strikes…Try nicotine replacement therapy [or] prescription non-nicotine stop-smoking medications such as bupropion (Zyban) and varenicline (Chantix).

Medical News Today

How to give up smoking: Ten tips…Nicotine in cigarettes is addictive, which is why people experience unpleasant withdrawal symptoms when they try to quit. Nicotine replacement therapy (NRT)…helps to ease some of the symptoms of nicotine withdrawal, such as intense cravings, nausea, tingling of hands and feet, insomnia, mood swings, and difficulty concentrating.

What is noticeable about all these – and they’re a representative sample of a large number of similar sites – is how discouraging they are! They tell you how difficult it will be to give up smoking, the unpleasant withdrawal symptoms and cravings (whatever that means) that would-be quitters will have to face and propose nicotine products (when the smoker is trying to escape from nicotine addiction) or prescription drugs which can only work by causing a chemical imbalance in the brain. No wonder quitting smoking seems to hard!

There is one site which appears fairly high on the list that I haven’t yet mentioned: Allen Carr. This comes nearest to what The Symonds Methods offers and, likewise, recommends no drugs or nicotine products but relies on a psychological approach. Incidentally, Allen Carr died in 2006, ironically from lung cancer, but his method is still available through the business he developed. The problem with it is that although he grasped intuitively why people smoke and therefore realised that a change of mind-set is enough in theory to get smokers to quit, he lacked the necessary medical and biological knowledge to explain clearly the mechanism of addiction, using instead crude similes such as ‘the little monster in your stomach’ and ‘the big monster in your head’.

Does the Allen Carr method work? This begs the question of whether any method of smoking cessation works. Smoking is a voluntary activity. If someone uses the X method and stops for, say, one year, and then a day later starts smoking again, does this mean X method has failed? No, it means the smoker has changed his or her mind about wanting to be a non-smoker. Nonetheless, a study was done in Holland in 2014 (https://doi.org/10.1186/1471-2458-14-952) which, in spite of methodological limitations, showed that in a company setting, 41% of participants were not smoking at thirteen months compared with 10% of controls – a four-fold difference. This is all well and good, but it still means that 59% failed to quit.

We now come to the method I have developed myself, which in all modesty I call The Symonds Method of smoking cessation. In theory, it should be 100% effective. Now hold on Dr Symonds, this is a bit over the top, isn’t it? Actually, no.

When a smoker sits down in front of me to learn how to be a non-smoker again, I ask them to give an undertaking that in the unlikely event they don’t happily stop after the first session, they will come back (without additional charge) for as many sessions as necessary until they do stop. The definition of success, therefore, is someone who doesn’t come back.

I have been accused of being self-serving by saying this, but I think it merely highlights the fundamental problem of smoking: in spite of being well aware of the risks, many smokers don’t want to stop or change to an allegedly safer way of continuing their nicotine addiction.

Text © Gabriel Symonds

Philip Morris tortures animals

Yesterday

Today

The tobacco giant, Philip Morris International (PMI), has applied to the US Food and Drugs Administration (FDA) to market what they call ‘modified risk tobacco products’ (MRTP), in particular, their heated tobacco contraption with the unpronounceable name of IQOS, or iQOS.

They start by putting their cards on the table: ‘PMI recognizes that cigarettes are a dangerous product.’ Then why don’t they stop making them?

In the application they submit evidence to support their claim that if smokers switch completely (the word ‘completely’ is redundant) to iQOS they ‘can reduce the risks of tobacco-related diseases.’

But now the Oh-so-honest American global cigarette and tobacco company, PMI, makes a devastating admission:

It is well known that the best way to avoid the harms of smoking is never to start, and for smokers, the best way to reduce the harms of smoking and the risk of tobacco-related disease is to quit. (Emphasis added.)

Note how they say that if you want to avoid the harms of smoking you should never start, which is true indeed, but if you are already a smoker and you quit, then you can only reduce the harms to which you have been exposed, not avoid them.

This is because, even if you stop smoking, the damage may already have been done. Certainly the risk of getting cancer will decline steeply as a few years go by after quitting but, alas, the risk will not go down to what it would have been if someone had never smoked.

Just to rub it in, they go on: ‘Cigarette smoking [accounts in America] for more than 480,000 smoking-related deaths every year, and more than 16 million Americans live with a smoking-related disease.’

So what does PMI do in the light of these shocking revelations?

They present themselves as the good guys:

PMI…has recently announced its goal to lead a full-scale effort to ensure that MRTPs ultimately replace cigarettes. Indeed, PMI envisions a smoke-free world where a broad range of MRTPs fully satisfies the continuing consumer demand for tobacco and nicotine products.

So PMI wants to be a public health champion, envisioning a smoke-free world where products such as iQOS will ultimately replace cigarettes. Note the assumption that there will always be – happily for PMI and its shareholders – a ‘continuing consumer demand for tobacco and nicotine products’. How about envisioning a nicotine addiction-free world?

All this, however, is merely a prelude to what I want to say in today’s post.

PMI, in their great humanitarian efforts to develop tobacco products that they hope will be  less harmful than cigarettes, have applied to the FDA for a licence to market their iQOS product. And what evidence do they present in favour of their application?

They subjected rats and mice to cruel experiments in which they were forced to breath iQOS fumes for six hours a day, five days a week for months on end. The fumes were either pumped into the boxes where the animals were confined, or in ‘nose only’ tests, they were held immobile in a kind of funnel with their noses sticking out of the end to be exposed directly to the fumes. The reason for this refinement was to avoid messing up the experiment by the animals ingesting more of the poison in the fumes by licking their fur as they would do if the whole body was exposed. The animals were then then killed and their noses, throats and lungs examined to see how much damage had been inflicted. Very little damage. Therefore iQOS is (relatively) safe for humans, they say.

Apart from the fact that there is no scientific basis for assuming that what happens or doesn’t happen in experiments on rodents has any relevance for humans, these abhorrent tests are manifestly cruel, causing pain and distress to these animals.

This research is reminiscent of the ‘smoking Beagles’ scandal in Britain in 1975 when an undercover investigation led to the exposure of experiments being done on Beagle dogs in a futile attempt to develop a ‘safer’ cigarette. The work was done by Imperial Chemical Industries (ICI). The dogs were restrained and forced to breath, by a face mask, the smoke from up to thirty cigarettes a day for as long as three years. The subsequent public outcry led to animal experiments for tobacco products being banned in Britain and Europe – but not in America.

It’s not as if the experimenters were using animals in the hope of finding a cure for cancer. Their object was to find a new way, acceptable to the FDA, of keeping people hooked on nicotine and their profits healthy to make up for the decline in cigarette sales.

Text © Gabriel Symonds

Stopping Smoking through Vulgarity

‘Smokefree’ is a catchy neologism used by the NHS Smokefree campaign. It’s supported by Public Health England which is part of the UK government’s Department of Health. So it’s quite kosher.

But what’s this? The Leicester City Stop Smoking Service at a quick glance looks similar:

As we can see, it offers not just any old licensed products to assist your efforts to become smokefree, but traditional licensed products! Well, bless their cotton socks. The manager, Louise Ross, comments: ‘Every time I see someone vaping I think: that’s another person NOT smoking a cigarette.’

And if the gung-ho Ms Ross were to observe a member of the public going about their business who is neither smoking nor vaping, would she think: ‘That’s another person NOT smoking a cigarette’? It seems to her the normal state of non-smoking is regarded as remarkable and a matter for congratulations.

In either event she seems to have a lot to be pleased about. How does she do it? With vulgarity. I promise I am not making this up. On the redoubtable Leicester City Stop Smoking Service website you soon come across a YouTube video of which the first written words, I blush to tell you, are: ‘Have you got the balls to stop smoking?’ It’s narrated by Gerry Taggart who, you will be glad to know, is a ‘Former Northern Island and Leicester City Defender’ – and I hasten to add he speaks like the gentleman he is throughout the short film. However, there is even a page labelled ‘Balls to stop’. It seems this website caters only to men. Incidentally, Gerry Taggart tells us he just woke up one day and decided he didn’t want to smoke any more – and he hasn’t. Once he put his mind to it, it was easy – and he didn’t need e-cigarettes.

Leaving aside for the moment the question of why you should need any sort of product to stop smoking, let us look at this stop smoking service’s wording in a little more detail:

We offer all the traditional licensed products (patches, mouth-spray, inhalators, Champix and many more), and advisors are skilled in helping people choose the right product for them.

Presumably the products don’t include e-cigarettes because these are not licensed for smoking cessation.

But they are included – very much so. The service emphasizes that it’s ‘ecig friendly’. That’s rather obvious: almost every page of the website shows pictures of e-cigarettes or contains articles about vaping.

If you want to stop smoking, or as one might say, be smoke-free, this conjures up a picture of giving up smoking and thereafter carrying on with your life without the need to poison yourself all the time by sucking tobacco smoke into your lungs.

But with these sorts of stop smoking services it must be rather disappointing for potential clients. The message is that in order to return to the normal state of being a non-smoker, they will instead of smoking be encouraged to put relatively pure nicotine into their bodies by other means and this could go on indefinitely. Or they may be offered a chemical drug to take for weeks or months. Or maybe clients will be offered nicotine products and chemical drugs.

On the other hand, rather than using a product to stop smoking, one could approach it in a different way that might be expressed by paraphrasing Ms Ross: ‘Every time I see someone vaping I think: that’s another person in the thrall of NICOTINE ADDICTION!’

Surely, someone who wants to stop smoking wishes to be free of nicotine in any shape or form. In this case, is so-called nicotine replacement the best that can be offered, or is it just second best? Why should anyone have to settle for second best? The fact that smoking substitutes are offered at all merely reinforces the fear that smokers already suffer: the prospect of never smoking again is almost too much to contemplate.

You don’t need ‘products’, let along nicotine-containing ones, to stop smoking. You just need to understand why you’re in such a pickle in the first place. Or, as shown by Gerry Taggart, you need a different mind-set. Then quitting is easy.

Text © Gabriel Symonds

They – Will – Cause – Death!

Dave Dorn is a trustee of the so-called New Nicotine Alliance (astonishingly, a Registered Charity in the UK). He claims that 80% of smokers who have taken up vaping have successfully switched from smoking because of what he calls ‘the pleasure principle’.

The gold necklace-wearing Dave gave a talk at the Global Forum on Nicotine in Warsaw in 2016. This was a ‘multi-stakeholder event [for those] with an interest in nicotine and its uses.’ The purpose of the conference seems to have been to promote e-cigarettes.

This is part of what he said:

The enjoyment that a smoker can have, the pleasure that a smoker can have from something which at the end of the day is not going to kill them. Something that presents less than 5% of the risk of smoking lit tobacco. The pleasure principle [holding up e-cigarette device] is what makes these things work. And this is why the Tobacco Products Directive in the EU, the FDA Deeming Regulations, all of which are concentrated on Quit! Quit! Quit! will fail. They – will – cause – death! They – will – cause earlier death because they do – not – allow for the pleasure principle. And that – for e-cigs – is the most important thing.

Death or pleasure – what a choice!

This is worth looking at in a little more detail. He also said, warming to his pleasurable theme, that some e-cigarettes taste absolutely gorgeous and give him more enjoyment than smoking did. The absolutely gorgeous taste presumably is not experienced through drinking the e-liquid – because it indeed could cause death if you did this – so presumably he must be referring to the taste of the vapourised e-liquid in his mouth as he sucks it into his lungs.

It is difficult to understand how you can perceive a taste in this way but it seems he has been doing this daily since 2009 instead of smoking. If you observe vapers, they suck at frequent if irregular intervals on their devices and a conservative estimate would be at least one hundred times a day. Now, is Mr Dorn saying that the reason he engages in this unnatural practice is because he gets pleasure from it? Does vaping produce in him a sense of bliss, a kind of ecstatic or orgasmic state so wonderful that he feels compelled to do it a hundred times or more every day for years on end?

In any case, he’s muddled about the idea of the pleasure principle. This theory was first propounded by Sigmund Freud, and he meant it as the instinct to obtain pleasure and avoid pain, particularly in babies and young children who seek immediate gratification of hunger and thirst. As the child matures this is tempered by the reality principle: the need to defer gratification and accept pain, if necessary. So Dorny means, not the pleasure principle, but merely pleasure.

Is pleasure in this context an illusion? And does it matter if it is? One patient said to me: ‘Maybe the pleasure of smoking is an illusion, but it’s a very nice illusion!’ But if smokers and vapers could understand why their perceived pleasure is illusory – and it’s easy enough for them to demonstrate this to themselves – would they be happy to carry on poisoning themselves for years on end?

My publisher, in the course of editing my book Smoking is a Psychological Problem, made the interesting observation that some people claim to enjoy whipping themselves, so who am I to say they’re wrong?

This is an valid point. I would respond that there is nothing wrong with self-flagellation if that is what adults wish to do. It may be harmful – the skin could be broken and infection set in – but the number of people involved is miniscule. I suppose there is a market for whips, but unlike smoking, it is not a multi-billion dollar enterprise resulting in seven million deaths per year worldwide.

Therefore, if vaping is (almost) harmless and vapers are deluded that it’s pleasurable why not just let them pretend to enjoy themselves?

Pleasure is also hyped by the purveyors of other alternative ways of gratifying the need for nicotine, such as with the new product called IQOS. I picked up a partially used pack of these things lying on the ground. It contained two ‘HeatSticks’. They looked like thin short cigarettes including a filter. The pack that I found was designated ‘Mint’ and indeed the things did smell like a combination of mint and tobacco. But it also said on the pack: ‘Tobacco enjoyment with less smell and no ash.’ So that’s all right then.

Well, it’s not all right. It’s very far from all right. The gloss on the IQOS packet ‘Tobacco enjoyment’ is false. Here’s why. There’s nothing pleasant or enjoyable about inhaling tobacco fumes. What happens is that when the nicotine in the fumes reaches the brain, the user is in a drugged state. Shortly thereafter, as the nicotine level starts to fall, he or she suffers (or is on the point of suffering) mildly unpleasant symptoms of drug withdrawal. It is the relief of these symptoms by the next dose of nicotine that provides the illusion of transient pleasure. Let poor Dave Dorn try a flavoured but nicotine-free vape liquid to experience his absolutely gorgeous taste and see for how long he wants to keep doing it.

Apart from that, take one hundred sucks of an e-cigarette or an IQOS gadget every day for twenty years and then let’s see what affect it has on your health.

Text © Gabriel Symonds

Are smokers getting a raw deal?

Tobacco is not an illegal substance yet the government is persecuting a minority. I think that’s a disgrace in a social democracy.

Sir Ronald Harwood
Playwright and screenwriter

There is in Britain a smokers’ rights group called Forest (Freedom Organisation for the Right to Enjoy Smoking Tobacco). The name tells you a lot. But are there people who want to be free to smoke tobacco even if they don’t enjoy it?

Forest paid for a survey to be carried out by the Centre of Substance Use Research. The subsequent report, published in December 2016, had the title and subtitle, ‘The Pleasure of Smoking’ and ‘The Views of Confirmed Smokers’, respectively.

It’s rather a good report and I’m glad I discovered it for the insight it gives into what’s going on in some smokers’ minds.

The problem, the report says, is that over the last thirty years tobacco control measures have changed smoking from ‘being a popular, socially accepted behaviour to…an anti-social, health harming, stigmatised behaviour [and that] smokers…have become increasingly marginalised.’

There is a difficulty here, it seems to me, in referring to smoking as a behaviour. I suppose this word is used in the sense of the way in which one acts or conducts oneself. I am not just being pedantic (although I am sometimes accused of pedantry), because the whole argument hangs on this word. As readers of my blog will be aware, I would characterise the activity of smoking as drug (nicotine) addiction rather than just a behaviour that one may engage in or not.

In a brief correspondence the first-named author of the report made the point that:

[T]o explain or reframe [smokers’] accounts of their pleasures [in terms of relieving nicotine withdrawal symptoms] seems to me to largely constitute the imposition of one interpretive frame (nicotine dependence) upon the views of smokers…many smokers did indeed perceive smoking as being pleasurable in ways other than having to do with the satisfaction of any nicotine dependence. (Emphasis added.)

 I’ll come back to this is a moment.

They surveyed 650 smokers who responded to an online questionnaire. Admittedly they were a self-selected group rather than a representative sample, but this didn’t matter for the purpose of the research. A significant finding was that ‘Nearly all participants (95%) cited enjoyment as their reason for smoking’ although ‘Over half (56%) of those surveyed said that they felt they were addicted to smoking.’

This implies there is such a state as an enjoyable addiction. Or is this a contradiction in terms?

Furthermore, ‘The majority of the smokers surveyed felt they were treated very unfairly (77%) or quite unfairly (14%) by government.’ I think they have a point. There is blatant inconsistency in the government’s attitude: cigarettes are on open sale, yet smoking is characterised as anti-social and disease-causing.

The claim of enjoyment as a reason for smoking is a recurring theme in the report. Smokers seemed well aware of the risks but nonetheless apparently decided to continue to smoke. Hence ‘many smokers themselves saw their smoking as a source of pleasure, a choice rather than an addiction.’ This is cited as one of the reasons that alternatives to smoking, particularly e-cigarettes, were not rated highly: they didn’t provide the same pleasure as ordinary cigarettes.

There are two assumptions that smokers and those in the tobacco control movement make. One is that smoking really is pleasurable, and secondly that if smokers are going to be persuaded to stop they will need a substitute for combustible cigarettes which will provide the same or a similar pleasure as smoking.

Both these assumptions are questionable.

First of all, what do smokers mean when they talk of the pleasure of smoking? And if we take them at their word, is this so great or important that it explains why they have a compulsion to do it twenty times a day, every day. Do they say, or think, forty minutes after smoking a cigarette, ‘By golly, that was marvellous! I must have another one!’?

It’s a strange kind of pleasure. There are many things I find pleasurable, for example eating chocolates. But I don’t eat chocolates every day and I certainly wouldn’t want to eat twenty in one day – I’d feel pretty awful if I did.

It’s also interesting that many smokers in the survey had withering criticisms of smoking cessation services and made the valid point that:

[I]f stop smoking services are going to succeed…they are going to have to be prepared to engage with smokers on the terms upon which those individuals view their own behaviour. This includes being willing to recognise the pleasurable elements of smoking.

This comes back to the question of whether smoking really is pleasurable. If one engages with and encourages smokers to say what, exactly, is pleasurable about it, we don’t get very far. Is it the smell? The taste? The sensation of the smoke going into your lungs? Do you experience some real pleasure every time you take a drag? It will soon become clear this doesn’t make sense. What other activity do you feel compelled to engage in twenty times (or more or fewer) every day and feel a rising panic if you’re not allowed to? With a little open-minded discussion, the reality soon emerges that in the normal sense of the word smoking is not pleasurable. Many smokers actually dislike smoking and wish they didn’t have to do it. Smoking seems pleasurable only because it gives temporary relief to the discomfort the smoker was in before he or she lit the next cigarette.

Some comments about the supposed enjoyment of smoking are very sad: ‘I enjoy smoking and there is very little in life that is enjoyable.’ ‘I suffer from lifelong depression and a sense of inadequacy. Smoking is the only thing that gets me through…smoking is my great source of comfort and peace. Without it there would be nothing.’ ‘My life has been difficult. Smoking has helped me survive.’

These unfortunate people clearly have serious problems. But rather than the methods currently being offered by stop smoking services, a different approach could be tried: they could be helped to demonstrate to themselves that, rather than their lives being almost unbearable without smoking, if they could recover from the drugged state that smoking induces, they would feel much better without smoking.

Text © Gabriel Symonds

Smoking in hospitals: right question – half-right answer

In a recent edition of The British Medical Journal (11 February 2017, p 232), that doughty source of the latest medico-political developments, there is a blog by a Dr Mary Black about the problem of smoking in hospitals, titled ‘Is it time we stopped colluding with smokers?’

I felt moved to send a response; it was published in the web-based version of the journal. This is what I said:

‘Dr Mary Black is properly concerned that smoking still goes on in many NHS hospitals due, it seems, to collusion by the staff who are too soft-hearted on patients. She cites her father, a doctor who was born in 1924 and started smoking in his teens. He ‘tried but failed to stop his tobacco use’ and died of a smoking-related cancer at the age of seventy-nine.

While it is regrettable that anyone should die of a smoking-related cancer, or of any kind of cancer for that matter, I would question the idea that he ‘tried but failed to stop his tobacco use’. With all due respect to Dr Black and the memory of her father, this is incorrect: he did not try to stop smoking; he only failed to stop, unfortunately for him.

The very idea of a smoker ‘trying’ to stop is wrong-headed and a distraction from the real issue (http://nicotinemonkey.com/?p=683). A smoker could be defined as someone who has failed to stop, and this is demonstrated every time he or she lights another cigarette, or pipe as in the case of Dr Black’s father.

She continues, ‘Misguided sympathy keeps the last vestiges of tobacco acceptability alive in the NHS…I now think that staff should focus their efforts on making sure that every smoker…gets nicotine replacement therapy and stop smoking advice’. Then she states the obvious, that the NHS should be smoke-free.

What would be wrong, then, with offering so-called nicotine replacement therapy to smokers who are admitted to smoke-free NHS hospitals?

This is what is wrong: for a start, nicotine replacement therapy is incorrectly named – it is cigarette replacement or nicotine maintenance therapy. But why should smokers need a replacement for cigarettes? This is the real collusion, based on misguided sympathy which in turn is based on misunderstanding of the nature of smoking. It also sends the wrong message: stopping smoking is too difficult to do on your own, so you need a drug in the form of medicinal nicotine to assist you. This disempowers and even infantilises smokers.

Of course the ‘stop smoking advice’ part is essential, but with the right sort of advice and understanding any smoker can stop easily – without nicotine. Many smokers actually dislike smoking (Proctor R, Golden Holocaust, University of California Press, 2011, p6) and may welcome the opportunity of enforced abstinence while in hospital. They would then be able to demonstrate to themselves that not only can they survive but also that they feel much better without poisoning themselves with nicotine in any form.’

Text (© Gabriel Symonds

What’s the Harm in Smoking Harm Reduction?

 

Smoking ‘harm reduction’ advocates seem to be working from the premise that some degree of harm is inevitable or unavoidable in relation to smoking. But this is manifestly untrue. The harm from smoking could be eliminated rather than just reduced – if there were the political will to ban tobacco products.

In the meantime the prevailing view seems to be that since some people will never want or be able to stop using nicotine, commercial interests should be allowed to supply it in the allegedly safer form of e-cigarettes. This line of reasoning supposes that smokers can be influenced through logic and common sense to switch to a less harmful way of absorbing nicotine into their bodies, but if this were true, why haven’t smokers abandoned cigarettes en masse in favour of e-cigarettes? Although many have, there are still 9.6 million smokers in the UK and 36.5 million in the US, for example.

A different picture presents itself if one looks at the question of whether anyone needs to use nicotine at all. The word ‘use’ in this context is the clue to what we are dealing with: drug addiction. The question, then, is whether it is or should be public policy for there to be millions of people walking around addicted to nicotine – in any form.

Many governments are working towards reducing smoking through what is called tobacco control, though this will be too little, too late for the nearly 6,000,000 smokers worldwide who die each year from smoking related diseases. (Source: the US Centers for Disease Control and Prevention.)

The dilemma is well put by Robert Proctor in his magisterial treatise on Big Tobacco, Golden Holocaust (2011):

Surveys show that most smokers want to quit and regret having ever started: tobacco is not a recreational drug, which makes it different from alcohol or even marijuana in this respect…smokers usually dislike their habit and wish they could escape it. (Emphasis in original.)

I would modify these statements slightly by pointing out that smokers may say they want to quit, but in practice they don’t really want to quit – not because they don’t dislike their ‘habit’ – but because they are addicted to the nicotine in tobacco smoke. And the reason they don’t really want to quit is because they have a fear of not smoking. Such inconsistencies are  characteristic of  addictive behaviour.

If smoking is seen for what it is – drug addiction – the question then becomes: why is the orthodox approach to the smoking problem only aimed at harm reduction rather than harm abolition? The former approach implies that nicotine use is here to stay, partly because there are benefits (pleasure, stress relief) people believe they gain from nicotine, of which it would be unfair to deprive them.

Part of this belief comes from the failure to appreciate that for practical purposes the only reason smokers smoke, or vapers vape, is to obtain relief from the discomfort of nicotine withdrawal; the alleged benefits are illusory. Unfortunately these simple facts tend to be obscured by doctors and others paying too much attention to research which seems to indicate that while smokers may indeed smoke to relieve the discomfort of nicotine withdrawal, they also smoke because of ‘triggers’ or ‘cues’ to smoke and because of the alleged release of dopamine stimulating the brain’s pleasure centre, etc. This kind of thinking, derived from laboratory studies or tick-box surveys, tends to support the erroneous idea that there are positive aspects of nicotine use. And this is one misguided reason why there is such an emphasis on tobacco harm reduction rather than abolition.

It’s also clear that the push to get smokers to change to e-cigarettes is largely commercially driven. For example, the ‘Third Vape Expo’ is scheduled to be held in Poland in March 2017. This is billed as:

The foremost professional vaping trade show. It is where industry players and experts showcase, share and incubate ideas. It is also where influencers and decision-makers seek and find solutions to propel their businesses…The Third Vape Expo Poland network now includes more than 2000 suppliers and buyers of vaping products from 15 countries worldwide.

There’s an interesting promotional video for this event featuring scenes from the September 2016 Expo: with catchy synthetic music in the background there’s no text or dialogue but the film shows hundreds of young people exploring the venue and visiting the different stands where vaping products are on sale. Many of them are merrily vaping away. It’s only too obvious that the purpose of this trade show is to entice young people to become long-term nicotine addicts.

Is this really the best way to deal with the smoking problem?

Text © Gabriel Symonds

The Art of Medicine and Stopping Smoking

19c8ox9fnk82ljpgThe distinguished medical journal, The Lancet, in June 2016 reported the results of a huge multinational collaborative effort to investigate the risks of psychiatric side-effects of two drugs used in smoking cessation: varenicline (Champix®) and buproprion (Zyban®); no evidence of increased harm was found compared with nicotine patches and placebo (dummy) treatments.

This must have been good news for the funders of this study, Pfizer and GlaxoSmithKline, who also happen to be the respective manufacturers of these drugs.

The side-effects that did occur were nausea, insomnia, abnormal dreams and headache, but, it is said, these were no more frequent in the users of these drugs compared with nicotine patches or placebo treatment.

Well, that’s nice to know. Or is it?

Were these methods any good for helping smokers quit? They found ‘Varenicline was more effective than placebo, nicotine patch, and bupropion in helping smokers achieve abstinence, whereas bupropion and nicotine patch were more effective than placebo.’ All clear?

Incidentally, the investigators only looked at smoking cessation rates at nine to twelve weeks from the start of the study. How many smokers relapsed after that we’re not told.

They recruited 8,144 smokers; and ten people contributed to the writing of the paper – all from the US except one: Professor Robert West, the self-styled ‘world expert on smoking and addiction’, who is from the UK. Of the ten authors, five were representatives of the drug companies. Of course, there was absolutely no conflict of interest whatsoever in the conduct of this study or the reporting of the results.

So, the drugs varenicline and buproprion were more helpful than placebo in getting smokers to quit and they don’t seem to cause psychiatric side-effects.

Now let me pose a question: is stopping smoking really so difficult that you need to take a prescription drug to help you do it? But it’s worse than that: the fact that drugs are offered at all for this purposes merely reinforces smokers’ fears that quitting on their own is, indeed, difficult. Or very difficult.

A commentator in The British Medical Journal (25 June 2016, p521) made an interesting point about this paper:

[I]t seems to me that a government serious about protecting its citizens from the harms of combustible tobacco would simply make the stuff unavailable.

That’s the obvious solution to the smoking problem, but instead of the government taking steps – or at least talking about taking steps – to bring this about, it’s shifted the problem onto doctors. And doctors, with varying degrees of enthusiasm, have taken it up: smoking is a chronic disease; the recommended treatment includes medicinal nicotine or prescription drugs, or both. Now it’s almost as if smoking cessation has been hijacked by the medical profession, and in the process it’s being made more difficult.

In my previous post (Depression, Busy Doctors and Winnie-the-Pooh) I noted how there’s sometimes an unfortunate tendency to reduce the art of medicine to a mechanical process: diagnosis – drug. It’s operative here too: stop smoking – Zyban®.

Instead of reaching for the prescription pad, what about talking with patients? The inspirational words of a famous doctor, Sir William Osler, should be kept in mind: ‘Listen to your patient, he is telling you the diagnosis.’ And in this situation, not just the diagnosis but the key to successful treatment as well.

The doctor (or smoking cessation councellor) needs to be interested enough to take the trouble to try and understand why smokers really smoke and why it seems so difficult for them to stop. It will then readily become apparent that all smokers are in the same situation.

They smoke because of nicotine addiction – and nothing else. The reason it seems so hard to quit is because of nicotine withdrawal symptoms. However, the withdrawal symptoms are not that bad. They consist of mental symptoms – mild anxiety and nervousness. Not uncommonly the only withdrawal symptom is a feeling or an idea of wanting another cigarette or a vague feeling of discomfort. If the smoker understands this and can be encouraged and supported not to worry about it, something wonderful will happen: it will go away!

Nicotine products and drugs are not only unnecessary but they make it harder to quit; they should not be used.

Text © Gabriel Symonds

Why NRT makes it harder to stop smoking

NRT, let me remind you, means so-called nicotine replacement therapy. Why ‘so-called’? Because nicotine is not a replacement for anything, nor is nicotine being replaced with something, so the name is wrong. It really means cigarette replacement but could equally well and more accurately be called nicotine maintenance therapy (NMT).

The idea is that, since stopping smoking is widely believed to be so difficult, you need some kind of stop-smoking aid to quit successfully. Well, why is stopping smoking thought to be so difficult? It’s because when smokers try to stop they feel uncomfortable – the dreaded withdrawal symptoms caused by the level of nicotine in the blood-stream falling. What are these withdrawal symptoms? Let’s do a Google search. I did it just now and got 885,000 results, the first of which gave the following list:

  • intense cravings for nicotine
  • tingling in the hands and feet
  • sweating
  • nausea and intestinal cramping
  • headaches
  • coughing, sore throat
  • insomnia
  • difficulty concentrating

Unfortunately – or rather I should say fortunately – this is not true­. I’ve asked hundreds of smokers about cigarette withdrawal symptoms and they all say the same things. Also, it’s remarkable that most smokers at first find it difficult to say anything at all about what they feel when they haven’t smoked for a while. However, with a bit of thought and prompting eventually they come up with one or two or three of these typical symptoms:

  • Feeling like they would like to have a cigarette
  • Thinking about smoking a lot
  • Irritability
  • Nervousness
  • Short-tempered
  • Difficulty in concentrating

Not uncommonly, the only symptom mentioned is that the smoker has a desire to smoke a cigarette and has none of the others in the list.

Two points need to be stressed: the above symptoms are mild; they are not that bad. Secondly, they are psychological (mental) symptoms. This does not mean, of course, that they are imagined or made up; they are real enough, but if a smoker is asked whether such feelings would ever become intolerable, the answer invariably is ‘No’. There is no actual pain and it is exceedingly rare for smokers to mention ‘intense cravings for nicotine, tingling, nausea, headaches’, etc.

Nervousness, irritability and difficulty in concentrating, then, are mental symptoms. Further, if smokers are asked what would happen to these feelings if they don’t have another cigarette, they consistently say that sooner or later they will go away!

Let’s get back to NRT – patches, gum or e-cigarettes. The underlying idea seems to be that, since the withdrawal symptoms are likely to be so awful, if you can relieve or prevent them by putting nicotine into your body by a route other than by inhaling it in cigarette smoke, you won’t experience nicotine withdrawal symptoms or will experience them to a lesser degree. Thus, you can ‘let yourself down gradually’, and then, after an arbitrary period such as a month or six weeks, you wean yourself off the NRT – and Bingo! – you’ll never want to smoke again.

The only trouble with this strategy is that it doesn’t work very well. At best only 20% of smokers who try NRT are still not smoking one year later.

There is another problem with NRT and it applies particularly to e-cigarettes: long-term continued use of nicotine, albeit in a supposedly safer form. This is because of the notion that some people seem to need nicotine, or they derive harmless pleasure from it. If they wish to labour under an illusion – and it may be perceived as a very strong or nice illusion – why shouldn’t they? Here’s one reason:

http://www.telegraph.co.uk/lifestyle/wellbeing/11506220/Why-I-wish-Id-never-taken-up-vaping.html

Observe someone vaping: he or she sucks on the e-cigarette device fairly regularly throughout the day, maybe 150 times – which is around 55,000 times a year. Why do they do this? Is it because it produces a real sense of pleasure or relaxation or other positive effect? They do it for the same reason that smokers smoke – to relieve the temporary discomfort of the withdrawal symptoms of nicotine.

If one puts nicotine into one’s body – by inhalation or through the skin or lining of the mouth – the addiction is maintained. Therefore, what needs to be done is for the smoker to cease putting nicotine into his or her body – by any means.

You don’t need a replacement for cigarettes, and you don’t need to put nicotine into your body.

Text © Gabriel Symonds