Doctors told to treat nicotine addiction as a disease

Smoking should be treated as a form of drug addiction, with smoking cessation services and interventions such as nicotine replacement therapy available to all smokers on the NHS, according to a report published by the Tobacco Advisory Group of the Royal College of Physicians.

The report calls for a major shift in attitude towards smoking. Doctors, other health professionals, and society "need to acknowledge nicotine addiction as a major medical and social problem" akin to addiction to certain hard drugs, such as cocaine and heroin.

Most smokers do not smoke out of choice, claims the report, but because they are addicted to nicotine. "We would like to see health professionals and the public accept smoking as a disorder that needs to be treated just like any other disease," commented Professor John Britton, chairman of the report and professor of respiratory medicine at the University of Nottingham. "At the moment smoking is seen as an optional activity."

Help to overcome nicotine addiction should be provided on the NHS in the same way as services to treat alcoholism and drug addiction. Nicotine replacement therapy is as cost effective as most other medical interventions, costing between £212 ($339) and £873 per year of life saved (1996 prices), claims the report.

It also calls for further research into the use and safety of nicotine replacement therapy in pregnant women, a third of whom continue to smoke.

Nicotine replacement therapy and other interventions, such as the antidepressant bupropion, which should be available in the United Kingdom later this year, double the quitting rate. Combining these methods with behavioural support such as group counselling can boost cessation rates to as much as 35% at one year.

Even though these effects seem small, providing these interventions widely on the NHS would "yield substantial returns in terms of the numbers of people who give up smoking," states the report, because smoking is so common.

In 1997 a quarter of adults were regular smokers. Although smoking has been declining over the past 50 years, it seems to have stabilised. By the age of 15, a quarter of children smoke, and about 50% of young adult smokers will still be smoking when they are 60.

Prevalence of smoking in children aged 11-15, according to parental habit, England, 1997

Expected years to live at age 35 and 65, according to smoking status and sex, United Kingdom, 1997

Even switching to low yield cigarettes may be counter-productive. In fact, people who opt for these brands compensate by smoking more deeply with very little, if any, reduction in the amount of nicotine and tar they inhale and little health benefit.

Smoking is the single most important public health problem in Britain and costs the NHS an estimated £1.5bn each year.

Professor Britton would like the Department of Health to recognise the problem of nicotine addiction and to lift the prescription restrictions currently applied to nicotine replacement products or to make them available over the counter at a reasonable price.

"It is totally unreasonable to provide expensive treatments such as statins on the NHS and yet to ban a more cost effective treatment that gives many more years of life," he said. In addition, cigarettes should be required to meet the same safety standards as other nicotine delivery products, such as nicotine replacement therapy, as set by the Medicines Control Agency.

"I would like to see cigarettes in their present form banned," said Professor Britton. "They should be made to be as safe as any other drug delivery devices." (See also Nicotine Addiction.)

Zosia Kmietowicz, London
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studentBMJ 2000;08:89-130 April ISSN 0966-6494