The Tobacco Advisory Group of the highly esteemed UK Royal College of Physicians has produced a report called Smoking and Health 2021 with the intriguing subtitle, A coming of age for tobacco control?

It’s an impressive document, written by fifty-one contributors, running to 169 pages, and includes 1,295 references. The authors are all highly qualified academics: professors, research fellows, senior lecturers, and the like. But I wonder how many of them, if any, have personally treated any smokers. This is an important point to which I shall return.

The ethics of tobacco control
The most interesting bit is at the end in a section called ‘Ethical aspects of tobacco control’ so let’s look at that first. It deals, somewhat shyly, with the question of whether tobacco should be made obsolete. Do they mean banned? It’s not entirely clear.

Starting with a scholarly consideration of one of the principles of ethical decision making, autonomy, (the others are beneficence, non-maleficence, and justice), they then raise the question, ‘Should we go beyond this autonomy-first approach [to make smoking obsolete]?’  The next sentence is the climax of the paper: ‘We consider that the answer to this is yes.’

At last, they’ve said it.

But one shouldn’t get too excited by this opinion. It seems they don’t mean banning tobacco but pursuing ‘tobacco control’ measures which, they modestly tell us, include the following (paraphrased):

Eradicating media promotion of smoking, prioritising the treatment of tobacco dependency, promoting quitting, raising the legal age of sale for tobacco products, silencing the voice of the tobacco industry, and thus make smoking obsolete within a generation.

A generation is said to be twenty-five years, but what should we do about the smoking problem in the meantime? What will all this eradicating, prioritising, and promoting achieve? Incidentally, what do they mean by ‘silencing the voice of the tobacco industry’? I wrote to the Chair of the Tobacco Advisory Group, Professor Sanjay Agrawal, and asked him, but have received no reply.

They propose ‘training clinicians to treat tobacco use as an addiction rather than a lifestyle choice,’ and they want to discourage smoking by increasing tobacco tax and educating people about the harms of smoking.

Balanced information
That’s all well and good, but then they go off on a curious tack. They want to ‘encourage switching from smoked tobacco to e-cigarettes and provide balanced information on other harm reduction options such as heated tobacco.’ (Presumably they wouldn’t want to provide unbalanced information.)

In pursuit of this goal they think ‘E-cigarettes [should be] included in standard protocols to treat tobacco dependency,’ as part of which they urge that ‘Nicotine product regulation should be used more proactively to reduce harm from smoked tobacco and promote substitution with alternative nicotine products. (I do wish they wouldn’t qualify the absolutes: you can’t have degrees of proactivity.)

What underlies this proposal? It’s evidence-based (!) information which leads them to make pronouncements like the following:

Addictive behaviours such as cigarette smoking are best understood as…a brain disease…because drugs such as nicotine change brain structure and function.

It is essential that smokers who contemplate or make a quit attempt are able easily to access the best evidence-based support and treatment to quit.

Unfortunately, they don’t seem to grasp the fact that whether smokers make a quit attempt or merely contemplate making one, it’s equally useless: either you smoke or you don’t.

Smoking is a brain disease – or is it?
The difficulty with their view of addiction is that although the brain is obviously affected by chronic nicotine poisoning as a result of which the urge to smoke may be difficult to resist, smoking nonetheless remains a voluntary activity. It’s not a disease in the normal sense of the word as something that comes unbidden, unwanted, and over which you have no control, like diabetes or arthritis.

The urge to smoke is largely a mental problem and it does smokers no favours to suggest they suffer from a brain disease from which, it is implied, they will need medical help to recover. Or worse, that if they can’t be cured of smoking they should be encouraged to continue their nicotine addiction by using allegedly safer e-cigarettes (vaping) or the new-fangled heated tobacco products instead.

Serious or perfunctory quit attempts?
In this report the phrase ‘quit attempt(s)’ appears sixty-seven times (once every two-and-a-half pages), but the only definition of it is to be found in the first part of a two-part statement:

For most people who smoke, quitting involves i) making a serious attempt to avoid smoking permanently and ii) successfully overcoming powerful urges to smoke over the subsequent days, weeks, and even years that follow.

Thus, i) means making a serious, as opposed, presumably, to a half-hearted or perfunctory attempt, and that this should be with the aim of avoiding smoking permanently. Obviously, it wouldn’t be to avoid smoking temporarily, so we can re-cast this as: ‘Quitting involves attempting to avoid smoking.’ But if it’s only an attempt, the person is still smoking, so i) is meaningless.

Then, ii): ‘Successfully overcoming powerful urges to smoke.’ If the overcoming were unsuccessful it would be pointless. So ii) can be simplified to: ‘Overcoming urges to smoke.’

Thus, we can reduce these statements about what it takes for a smoker to become a non-smoker, to: ‘Quitting smoking means stopping smoking and not starting again.’ But this is merely stating the obvious.

And by the way, who says the urges to smoke will be powerful? What if they’re only of medium or mild strength?

Blinding themselves with science
The authors of the report also apply their minds to the problem of relapsing after a period of abstinence:

This is partly due to the intensity of the withdrawal syndrome associated with abstinence, and partly to the ability of conditioned stimuli, such as being in a place where the individual previously smoked, or seeing someone else smoke a cigarette, to continue to elicit drug-seeking behaviour even after several months or even years of abstinence.

The reference for this statement is to a paper published in 2004 from which, in the turgid opaque prose all too common in medical papers, we learn it’s based on the hypothesis that

Stimulation of the dopamine projections to the medial shell and the core of the nucleus accumbens plays a complementary role in the development of nicotine dependence.

They opine further that

The evidence that the primary role of the increased dopamine overflow…is the attribution of incentive salience to cues associated with delivery of the drug and the transition to Pavlovian responses to these conditioned stimuli. (‘Attribution of incentive salience’ – what a wonderful cliché!)

Whatever this is supposed to mean, it’s derived from cruel animal experiments of unknown relevance to humans.

What it all boils down to, it seems, is that in addition to the alleged intensity of the withdrawal syndrome, whatever that is, merely being reminded of smoking is what makes people want to smoke. Consequently, we now we have two reasons why smokers find it so difficult to cease poisoning themselves with tobacco fumes: the psychological aspects and the hypothetical brain disorder.

Another drawback of the dopamine hypothesis is that it reinforces the belief that quitting smoking is terribly, terribly difficult because of a supposed brain abnormality.

The problem with the evidence-based approach to the treatment of the so-called disease of nicotine addiction is that our authors seem to have blinded themselves with science.

If you talk with real people who smoke, however, it will soon become clear that for the practical purpose of helping smokers become nicotine-free, the dopamine hypothesis is merely a distraction and, indeed, counterproductive. This is because, in my experience of having successfully treated hundreds of nicotine addicts, if smokers can be assisted to acquire a positive attitude to stopping smoking and all nicotine use, they will have little or no difficulty in resisting the urge to smoke, brain disease or no brain disease.

Distinct processes
The lack of understanding about smoking by these authors is further shown in the following sentence:

The initiation of the attempt [to quit smoking] and the success once initiated are distinct processes.

This is ivory tower thinking. Quitting smoking and staying quit are not processes at all; they’re one and the same state. As I’ve already pointed out, either you smoke or you don’t. This means, for smokers who wish to stop poisoning themselves with tobacco fumes, that you smoke your last cigarette and thenceforth remain in the happy state (other things being equal) of freedom from nicotine addiction.

To talk of this as a process you have to initiate, as if you’re riding a horse and first have to mount the animal, and then, as a separate procedure, persuade it to move forward without you falling off, just about makes sense. But if you’re a smoker, once you extinguish your last cigarette – that’s it! You’re a non-smoker.

Of course, you need to stay a non-smoker, but it’s splitting hairs to regard it as something distinct. Otherwise, you’re handing the smoker an excuse for failure on a plate, or rather, on an ashtray. He or she can say, ‘I initiated an attempt to quit smoking, but couldn’t succeed in the process of succeeding in quitting.’ This is nonsensical.

A smoker may feel the urge to smoke again after a period of abstinence, but whether to act on this urge is a voluntary decision. It cannot be compared to a real brain disorder, like epilepsy, which is entirely outside the sufferer’s control.

Counsel of despair
Further, the suggestion that smokers should be encouraged to switch to e-cigarettes or heated tobacco products is a counsel of despair and almost an insult. It implies they will never be able to cease using nicotine and the best that can be achieved is to switch their nicotine addiction to an allegedly safer way of continuing in its thrall, likely for the rest of their lives.

Also at the heart of the problem is the following statement:

Relapse prevention over the longer-term is therefore challenging, and this contributes to declining rates of sustained abstinence over time. For this reason, many tobacco control policies focus on reducing the availability and visibility of smoking, to reduce these cues and denormalise smoking.

This is the trouble with so-called tobacco control policies. If smoking is to be merely controlled as opposed to being abolished or banned, this implies there are circumstances where smoking is legitimate or acceptable. And what, pray, are these?

In any case, with the approach they advocate it’s hardly surprising that we have ‘declining rates of sustained abstinence over time.’ (The words ‘over time’ are redundant.) Furthermore, to say ‘many tobacco control policies focus on reducing the availability and visibility of smoking’ is unclear. The word ‘smoking’ should be replaced with ‘tobacco’ and the sentence re-written thus:

Tobacco control policies should focus on reducing the availability of tobacco to denormalise smoking.

If the availability of tobacco were reduced to zero, the visibility of smoking would take care of itself.

But this will only be achieved in the foreseeable future by banning tobacco.

Text © Gabriel Symonds