Persuading families not to smoke at home: a how-to guide from the UK National Smoking Cessation Conference

From Laura Jones at the University of Nottingham comes this review of research on initiatives to discourage people from smoking in the home, presented in an audio clip and slide show.

The abstract page contains (as standard) a declaration of no interest, even though it was funded from the UK Centre for Tobacco Control, some of whose staff have clear interests in the nicotine replacement therapy market.

Personally I found the soundtrack quite difficult to listen to, especially when Dr Jones says that inadequate rules about where smoking is allowed in the household (that is, rules that don't amount to a complete ban) might as well not be in place at all. I find it difficult to accept that level of what is politely called 'intervention' where I live (in fact I need not worry on that score as I neither smoke nor have children).

I can see tobacco control experts being content with an absence of legislation in this area: all the more reason to undertake further research into the most effective ways to persuade people not to expose their children to 'second-hand' smoke. But at what point (to paraphrase the title of Chris Snowdon's blog) will the velvet glove become the iron fist?

And will the children whose health is of such concern today find themselves at the receiving end of an iron fist in the future?

Start Champix earlier in quit attempt and it might work, says Pfizer study!

Pfizer's new study claiming that starting earlier on Champix would improve its effectiveness couldn't come at a better time. This drug has maimed countless lives, and is the subject of a black box warning. Peter Hajek of the UK Centre for Tobacco Control Studies (no competing interests of course) and colleagues 'compare the effect to making food look unappealing. "The level of hunger pangs may be the same, but it is easier to resist a food that has become less tempting," they note.'

This is a poor comparison. Messing with someone's brain doesn't resemble disfiguring somebody's dinner. 

The people at the UK Centre for Tobacco Control Studies know how ineffective many quit attempts are.  Another member, Tim Coleman expressed this view in November:

Currently stop smoking services are evaluated on the percentage of 4-week quitters, but around three-quarters relapse after this date. 

His solution was to attempt to get funding for people to take smoking cessation drugs (NRT) in the longer term as a kind of damage limitation exercise. A similar assessment comes from the Tobacco Control blog, discussing Turkey's new anti-smoking facilities:

It’s worth remembering that, if the Turkish experience mirrors international evidence, every hotline call represents several other smokers who have decided to quit on their own. Even in countries with excellent, and often free, quit resources, more than 80% of smokers quit cold turkey (pun intended!) on their own.

An editorial discussing this study comments: 

One in five Americans smokes [...] and only between 4 and 7 percent of those who try to stop succeed. 

 These people know what a poor success rate smoking cessation drugs have. Yet huge amounts of money are spent promoting them, even on solutions like Champix which occasionally spell disaster for those taking it and their families.  

ASH Scotland is on a crusade to persuade the managers of Scottish mental health facilities to remove smoking rooms. Their next event will 'explore the new implementation guidelines' published by the Scottish government. No doubt they will be urged to ensure that smoking cessation meds are always available to patients who are forced into a no-smoking regime at a catastrophic time in their lives. Stopping people from smoking trumps every other consideration.

BMA urges conference to distance itself from pharmaceutical interests: whistling in the wind?

A startling cautionary note has come from the World Health Organisation, urging smoking prevention activists to bite off the hand that feeds their activities. If not that, to get a respectable distance from other relevant commercial interests in the field. Delivered at a pharmaceutical-industry sponsored conference, it remains to be seen how much difference the acknowledgement of a competing interest in the field will make.

Chris Snowdon has covered this issue, with some background.

Our own resident smoking cessation medication trade-fare cum training school, the UK National Smoking Cessation Conference, similarly relies on pharmaceutical sponsorship. Looking at the list of delegates am I the only one to be amazed how much money changes hands in the effort to stop people from smoking? Most if not all these people are salaried, many of them specialising in smoking cessation or 'health improvement'. By the time the conference takes place in June there will probably be over 600 of them on the delegate list, and of course many more who won't make it.

What gives government such a kick out of employing people to stop people from smoking ... from buying a product which gives them so much money. Tell me it's conscience, and I won't buy it.

It gets harder to believe that one can view pharmaceutical corporations as primarily interested in the good of our health. They will be the main beneficiaries of the Traditional Herbal Medicinal Products Directive, which aims to outlaw the sale of herbs as medicines (due to be implemented on 30 April this year), thus removing access to herbal remedies by people all over Europe – including remedies originating outside Europe. (You can sign a petition here.*) Europe also wants to remove access to smokeless tobacco and e-cigarettes, also on the grounds of their supposed risks to the public. This will leave the smoking cessation business to the pharmaceutical corporations.

What makes Europe step into line with the commercial imperatives of these hugely powerful pharmaceutical corporations? Is it credible that pharmaceutical interests will be acknowledged to be as commercially powerful as that of the tobacco interests, and therefore just as suspect?

Those who make a virtue of a level playing field when it comes to applying smoking bans don't apply a level playing field in the economic and political arenas. Pharmaceutical companies and tobacco companies are clearly rivals in the market for nicotine, but tobacco companies face a ban on advertising and sponsorship. This means that no one depends on them for income, including the media. Pharmaceutical companies on the other hand make drugs, and government needs their cooperation. Pharmaceutical companies are seen as a source of good health and high quality, prestigious employment. They tick all the right boxes.

CorporateWatch quotes The Guardian in its general overview of pharmaceuticals.

There were times not long ago that drug companies were merely the size of nations. Now, after a frenzied two-year period of pharmaceutical mega-mergers, they are behemoths, which outweigh entire continents. The combined worth of the world’s top five drug companies is twice the combined GNP of all sub-Saharan Africa and their influence on the rules of world trade is many times stronger because they can bring their wealth to bear directly on the levers of western power.

With so much influence (employing two lobbyists for every member of the US Congress), it isn't surprising that commercial interests outweigh those of public health:

The US government has shown many times how it backs up its pharmaceutical industry at the cost of ordinary people the world over, including its own citizens. In September 1999 the US government decided to grant US pharmaceutical corporations the patent rights over drugs invented with public funds – six HIV/Aids drugs, as well as anti-malarial treatments and other medicines of vital interest to developing countries. The government had the right to use the drugs in public health initiatives, but chose to protect the commercial interests of its industry instead. 

I think I won't hold my breath for smoking cessation specialists to stop depending on pharmaceutical influence.

ASH declared interest in GlaxoSmithKline, 2001

In 2001, then head of Action on Smoking and Health Clive Bates wrote to the Chief Executive Officer of GlaxoSmithKline, protesting at the appointment of a tobacco industry representative Derek Bonham on its board of directors. Bates felt that a conflict of interest was involved: the public already in 2001 had identified collusion between pharmaceutical and tobacco interests:

There are already campaign groups that claim the tobacco industry and pharmaceutical industry have a symbiotic relationship that is parasitic on the smoker. I believe it would be highly damaging to the category, to the company and the industry as a whole would be highly damaging to feed that cynical perception.

News to me if the public had any such 'cynical' perception ten years ago.

The letter says:

1. that Action on Smoking and Health had a 'small holding' in GSK
2. that Action on Smoking and Health was instrumental in getting smoking cessation treatments accepted by the Department of Health in London

It identifies policy measures, such as raising prices and increasing regulation of tobacco, that benefit 'the smoking cessation market' at the expense of the tobacco market.  'Every time a smoker switches to "lights" as
an alternative to quitting the market for smoking cessation is diminished.' Clive's letter lists measures that he believes promote the smoking cessation market at the expense of tobacco:

• Restrictions on smoking in public places and workplaces
• Marketing restrictions on tobacco companies
• Higher tobacco taxation
• Greater NHS involvement in smoking cessation
• Regulatory measures to be applied to tobacco products.

Tobacco companies and pharmaceutical companies carrying nicotine replacement treatments are competing for the same market: that of smokers. To that extent, there is a logical conflict of interest.

Nicotine replacement therapies became available on the NHS in April 2001. The Guardian was excited about this move soberly  reporting John Britton's then-cautious estimate that NRT doubled a smoker's chance of quitting (the claim escalated to a quadrupling of the cold-turkey quit rate). In those days one could say:
'this doubled success rate only applies if you are ready to stop. Taking NRT cannot make you more committed to giving up smoking or transform you into a non-smoker, although it can help end the psychological habit of reaching for a cigarette.'

Even giving nicotine treatments to kids as young as 12 didn't raise any scepticism among Guardian writers on health.

The early days saw campaigners fighting for greater availability of NRT, using the same harm reduction arguments now used by campaigners for e-cigarettes. Said Anne McNeill (now at the UK Centre for Tobacco Control Studies): 'It's simple really - the more the regulators place stringent regulations on the use of NRT, the more likely it is that people will continue to smoke, and then die as a result.'

My question is – the smoking cessation market is important to Clive Bates. No doubt he believed it would help smokers to give up smoking. But what is it worth (as an investment) to the NHS, when it's clear that much of it will go out free on prescription?

Just asking.

Three-quarters relapse after four weeks, says smoking cessation researcher

You read it here first. Well maybe not.

Ex-smokers should be kept on medication for much longer to prevent them relapsing, concludes an NHS cost-effectiveness evaluation.

The systematic analysis of trials found the current system - where quitters were supported for four weeks should be extended – with medication prescribed for at least three months.

Currently stop smoking services are evaluated on the percentage of 4-week quitters, but around three-quarters relapse after this date [emphasis added]

Do they tell you this at the same time as they are saying you are four times more likely to give up with NHS help? Okay then: a method that doesn't work too well could be given three times as long to work (as the austerity cuts bite). That sounds very cost-effective.

Tracking people for longer than four weeks is probably a good idea on the basis that the non-drug support is equally as effective as the pharmaceutical support, and many services probably do it. A Wandsworth GP is reported in this account to be cautious about too much reliance on drugs: 'support is key,' he says. The report on the cost-effectiveness of treatments however is authored by Tim Coleman, a man whose career rests on smoking cessation medications, whose competing interests are listed here. Some promotion of smoking cessation drugs is to be expected from someone with his track record.

Why is it that interests in pharmaceutical companies don't arouse any suspicions in official minds, when corner shops are mistrusted because of their tobacco connection, in spite of their meagre takings per pack? If a competing interest is enough to get you excluded from the policy debate, as the tobacco companies are, why are Tim Coleman and his colleagues still involved? Are they supposed to be above the suspicion associated with competing interests because they are involved in health issues or because the focus of their work is against tobacco?

Jobs for the boys? Get into smoking cessation, son, you'll have a job for life! Government will support all your endeavours!

Other interests also operate in the field of smoking cessation drugs: this report shows a postcode lottery of stop smoking cessation medications depending on commission earned by pharmacies for treating patients with them: earnings between different PCT areas range from nearly £12 to over £140. (That looks like a fair attempt to reduce health inequalities.)

Like anything else, access to smoking cessation drugs depends for most people who want to quit on government funding . Considering the cost issues and the uncertainties and dangers of various treatments, readers who want to stop smoking should be aware of this page. Competing interest: John Polito is a smoking cessation adviser who is opposed to drugs, and he has books to sell.