Smokers need more help to quit

There is another price rise on the way for smokers, but smoking policy should be designed around the needs of puffers.

Photo David White

New research shows that the April 2010 tobacco tax rises nudged many smokers into action, doubling the number trying to quit. More quit attempts are good news. How many actually succeeded isn’t clear. The chemical snare of nicotine holds smokers in an awfully tight grip. In the new year, smokers will get another price shock, a 14.6% tax rise. Although price jumps catalyse many smokers to quit, smokers need much more help giving up, although not in the way we might think.

The Government helpfully provides toll-free help lines, counselling and subsidised quit medicines, at a personal level, all of which is good. But missing are the policies to specifically unspring the chemical addiction trap. Many smokers would dearly love to quit – about a third try each year. The reality is willpower isn’t always enough, something tobacco manufacturers know very well. That’s why they ensure all cigarettes are high in nicotine, setting the chemical trap that smokers find so difficult to escape from.

Here, that trap is particularly tightly sprung. A 2010 study found that out of eight countries, New Zealand-sold cigarettes were second only to those sold in South Africa for the amount of nicotine they contain. New Zealand smokers were getting 1.62mg of nicotine per cigarette, compared with 1.77mg in South Africa, and more than those in Australia, Brazil, Canada, Germany, Japan and Switzerland.

If we wanted to give smokers more help, there are three big changes we could make. We could stop punishing smokers and their families. We could exempt very low nicotine cigarettes from future tax increases to create a class of new less-expensive cigarettes. We could annually ramp up the tax on addictive cigarettes. Instead of taxing smoking, tax should target nicotine. By gradually smoking fewer of these addictive cigarettes each year, smokers could still have 20 cigarettes without spending any more on tobacco, while greatly reducing the nicotine inhaled. We could compel manufacturers to come clean on the addictive strength of their products by printing nicotine content on the packet. And we should legalise the sale of e-cigarettes, vaporised nicotine inhalers that mimic the smoking experience, but are dramatically safer, cut cigarette consumption and aid quitting.

Tobacco addiction begins as a want, grows into a strong desire or craving, then becomes an insistent need to smoke. This cycle repeats itself endlessly. Many smokers are distressed and anxious if they cannot smoke. Nicotine is the main substance keeping 80% of smokers addicted. In a 2008 survey of over 1130 New Zealand smokers by the University of Otago, 86% supported laws to make cigarettes less addictive, even if it made smoking less pleasurable.

Mark Twain famously said, “It’s easy to quit smoking. I’ve done it hundreds of times.” Smokers cycle in and out of smoking, quitting in desperation, moving from tobacco to nicotine products, and then back again with shame and regret. Recent Ministry of Health surveys show that 60% of smokers tried to quit in the past five years, making two attempts a year, and about 6% probably succeeded. Recent tax increases have helped, cutting sales by 17% since 2008. More smokers would quit if they could “quit and switch”. An ideal switch would be to a cigarette lookalike that emits harmless vapour, replaces nicotine, replicates smoking rituals and throat sensations, and saves money.

The electronic, or e-cigarette, replaces the whole experience of smoking, except for lighting up, whereas nicotine medications only replace nicotine. After a few months many switchers are tobacco-free and stop using their e-cigarette. Some choose to continue using nicotine for some time. Time and again I have seen a smoker’s eyes light up when they see and try an electronic cigarette. Over two million American adults now use them, with the numbers still growing.

At the University of Auckland’s clinical trials research unit, hundreds of smokers are being enlisted to further test the impact of e-cigarettes on stopping smoking. Experienced users puff them without pause and can extract as much nicotine as from a cigarette. But nicotine alone is less addictive than tobacco. The Ministry of Health rates the vapour as far safer than cigarette smoke. Regulation of this evolving product is desirable as part of a move towards regulated sales.

Smokers regard e-cigarettes as a way to enjoy nicotine without getting killed – a laudable public health aim. Medsafe says they are unapproved medicines and has banned their sale. Cutting smokers a bit of slack on e-cigarettes would help enormously. Local pharmacies and petrol stations sell e-cigarettes with nicotine-free cartridges. The only way New Zealanders can legally get the nicotine cartridges is importing them via the internet for personal use. But if we are serious about the goal of becoming a tobacco-free nation by 2025, smokers will want to be able to buy inhaled recreational nicotine products, instead.

On January 1, 2012, the tax on cigarettes will rise, made up of a 10% legislated increase plus a 4.6% inflation adjustment. In future, further tax rises on cigarettes could double their price. If very low nicotine cigarettes were exempt, they would effectively be half price. That would increase demand, which manufacturers would want to meet. Recent studies show that smoking very low nicotine cigarettes helps smokers quit. If smokers cut back to five high-nicotine cigarettes a day and smoke them intensively, inhaled nicotine is halved. Smoking very low nicotine cigarettes adds little nicotine to the bloodstream.

New Zealand’s 600,000-plus smokers have never been told how much nicotine is in their cigarettes – the best measure of their addictiveness. Worldwide, cigarette companies do not inform governments, and most governments do not enquire, or require that smokers be told. In this country, the Government has powers to end this secrecy. The health sector is working to treat more patients for their smoking. But with some 94% of quit attempts ending in relapse, offering medicinals and counselling will not fix the problem before 2025. The Government needs to step in and do what smokers, as smokers (not as patients), want. Of course, some willpower is still needed, this time from the Government.

Murray Laugesen, a public health medicine specialist, researches ways to reduce smoking. He chairs the End Smoking NZ trust. www.healthnz.co.nz

Reducing tobacco smoking addiction

Photo David White

Problem: All cigarettes on sale contain high amounts of nicotine. No very low nicotine, less-addictive cigarettes are on sale.
Remedy: Exempt very low nicotine cigarettes from any further tax rises. As they are half the price, demand will increase. Tax high-nicotine cigarettes more. Fewer high-nicotine cigarettes will be smoked. Less nicotine will be inhaled.

Problem: Manufacturers do not dislose cigarette nicotine content.
Remedy: The Government can require nicotine content to be printed on the packet. Then smokers can gradually decrease nicotine by changing to a different brand.

Problem: Electronic cigarettes with nicotine safely mimic the smoking experience, but their sale is illegal.
Remedy: The Government needs to listen to smokers and change the law to permit regulated sale.

Problem: Some are worried that cigarette lookalike products would perpetuate smoking. Smokers can buy nicotine-replacement medications but not products to simulate the smoking experience.
Remedy: Cigarette lookalike products help people to quit partly by replacing the smoking rituals and sensations. Make nicotine e-cigarettes available in local shops. Let these safer products compete for the smoker’s dollar.

We have received the following letter in response to this story:

Murray Laugesen (“The will to quit”, December 17) has the right idea. Smoking is not just an addiction to nicotine. For many, the hand-to-mouth habit is the hardest to break. Weaning us off with pills is not the answer. Especially when the pills have horrendous side effects and are an antidepressant likely to make people need them for the rest of their lives. Please give us e-cigarettes. If they came with progressively less nicotine content, even better.
Paula Yeates
(Napier)