Philippe Boucher's Rendez Vous Martin Raw
Rendez-vous with Martin Raw
Tobacco control expert
By Philippe Boucher
Monday, March 6 2000
Thank you Martin for accepting our rendez-vous.
May I ask you to introduce yourself ?
I am a freelance consultant and honorary senior lecturer in public health, and I came into the tobacco control field through a psychology background.
My degree was in psychology and physiology, and then I went to the Institute of Psychiatry in London to do clinical psychology, which is where I met Mike Russell in 1974. Mike Russell is a psychiatrist who in the late 1960s, when he was at the Institute of Psychiatry, at the Maudsley Hospital in London, became interested in treating addicted smokers.
He started treating smokers at the Maudsley and also in the early 1970s started a large controlled trial of brief advice given by GPs, which was published in 1979 and established a bench mark for GP interventions.
He also pioneered modern research into the role of nicotine in smoking.
He first met Ove Ferno, of AB Leo in Helsingborg, at the 1971 world conference, and over the next few years Ferno got Mike interested in the still fledgling idea of nicotine chewing gum.
Mike built a team of researchers many of whom are still prominent in the field now, for instance Martin Jarvis, Stephen Sutton, Robert West, Peter Hajek, Gay Sutherland, John Stapleton, Jonathon Foulds, Lesley Owen, Ann McNeill. Mainly through Mike's influence I did my masters dissertation on smoking cessation. At the end of the course my clinical psychology boss and I wrote a grant application to the Department of Health to develop and evaluate a clinical psychological service in general practice. While we waited for an answer, Mike took me on to help run the Maudsley Smokers Clinic, on the understanding that I would probably only be there a few months. In the event the DoH reviewer turned us down. He saw "no role for psychology in general practice". So I stayed with Mike.
I started with a (pretty awful) psychological treatment trial but Ove Ferno, of AB Leo in Sweden, was just getting to know Mike at the time, and although Mike was not very interested in nicotine gum, he agreed we would have a look at it. So I started assessing our clinic clients for dependence, and in the end found myself rating the vast majority as very dependent. We did an uncontrolled trial of the gum, followed by a double blind placebo controlled trial which Martin Jarvis ran, and as you know, was published in 1982 in the BMJ; the first in the world.
I was with Mike from 1974 until 1980, when I went to do my own research at St George's Hospital Medical School in south London. I went freelance in 1988 and from 1989 to 1995 was half time deputy editor of "Addiction", probably the most fun I ever had in a proper job. From 1995 onwards I have been full time freelance, working mainly on cessation but also on economic aspects with Chris Godfrey (including the relation between consumption and employment), tobacco subsidies and smuggling with Luk Joossens, and most recently clinical guidelines with Ann McNeill and Robert West. My main project now is the WHO Europe Partnership Project.
First question : You are involved in WHO Europe's Partnership Project. What is it and what do you hope it will achieve?
It is called the Partnership Project to Reduce Tobacco Dependence, and the partnership referrred to is between the public and private sectors. It is funded by the four main pharmaceutical companies who have treatment products for smokers, and they sit on the Project Group, which oversees the project. Also on this group are WHO project management staff, official government country representatives from the four initial target countries (UK, Germany, France, Poland), experts from these countries, the the five activity leaders, and representatives of supporting organisations, including the European Commission, the European network ENSP, a consumers organisation, the European SRNT, Europharm Forum, European nurses organisation, European medical associations, and a government policy advisor. Final decisions on the work programme are made by WHO project managment. The five activities are: monitoring smoking status and changes in it; regulation of tobacco and tobacco dependence treatment products; smoke free places; supporting the implementation of evidence based treatment (I lead this one);
communication of the health message.
What I hope it will achieve generally is to increase our capacity to mitigate the public health effects of tobacco across Europe, and in terms of tobacco dependence treatment, I hope it will get the issue onto the agenda of health care systems.
2) You have been involved in the development of NRT almost from the beginning. How big an impact do you think pharmacological treatments for smokers have and will make?
I want to answer this by first putting the point in context: over the last 40 years or so the main approaches to helping smokers stop have been motivational and behavioural. All pharmacological treatments have done is add a small (except in treatment clinics) additional proportion of stoppers, but in the context obviously of these population/behavioural campaigns. But even with low-ish additional cessation rates, these effects are potentially so widely applicable, and cheap, that they represent really excellent value for money: they are extremely cost effective. So I think their impact on public health will be huge.
3) Do you have any concerns about public-private partnerships like the WHO Partnership Project, about working with the private sector? What about the impact of the mega-mergers in the pharmaceutical industry? aren't the consumers to become quite powerless in front of such giants?
I do have concerns about public private partnerships and the balance of power, and in fact just ten or so years ago I would have been quite suspicious about such a concept (and probably totally against it). What sways me is pragmatism and a public health perspective, as I see it.
I think that to a large extent the companies share a common goal with us, which is to reduce the damage to health done by tobacco. I know they also have the goal of making profits, but (so do I as a freelancer) so long as our goals coincide, and I can continue my work to my standards, and without interference, then I welcome the partnership. I also welcome the possibility of doing work, especially internationally, which simply did not get funded by public health authorities in the past. I am now doing work I always wanted to do but never would have been able to. As for mergers I don't really know what their impact will be. In the end I am a public health professional trying to achieve what I can, but I think at the moment smokers are even more powerless in the face of the tobacco industry.
4) What would you see as being the key issues with pharmacological treatments, for example, concern has been expressed about how expensive they are for ordinary smokers.
About what should be an adequate price?
I think the key issue is accessibility - the excessively onerous (compared with tobacco products) regulatory framework which makes it so difficult for unwilling smokers to get NRT (and in Europe soon bupropion) as opposed to tobacco, and price. I would like to see these medicines available as widely and as cheaply as possible. I suppose an adequate price is one people can afford, and ideally in the longer term, all help for dependent smokers should be available through health care systems (which in my country would mean 'free').
5) Some people say that smoking cessation should not be over-emphasised at the expense of broader tobacco control programmes. There is also the question of which smoking cessation programs are the most effective?
Is the multiplication of hospital based smoking clinics the best way?
Are physicians really needed or could people self medicate themselves out of tobacco dependence?
It should not be. But I think cessation has been massively under-
emphasized over the last 30 years and at last the balance is being redressed. No-one (I hope) is saying treatment is the answer, although Richard Peto argues compellingly, on the basis of epidemiological data, that cessation, as opposed to primary prevention, is extremely important. But I believe the answer is in balance. I don't think cessation and treatment would work unless they existed in a culture that supported the idea of stopping smoking. Education and information campaigns push smokers towards wanting to stop, which many then do. However the majority do not, and we then have a responsibility to help those who are addicted. I see that as the role of the health care system.
As for what is most effective - arguing about that would amount to arguing amongst ourselves. ALL smoking cessation interventions are more cost effective than many other health care interventions. That is the message I want to convey to those who fund health services.
6) Last but not least a personal question. You have been in this field for 25 years. What is your secret for surviving so long? But maybe are you about to quit? I am asking because after 13 years or so I certainly -- sometimes -- feel for myself the envy to do other things.
I have never seriously tried to quit the field. I do get tired, especially in the last year, but I have survived by constantly finding new challenges. First it was treatment research. Then research on the organisation of treatment services. Then I edited a journal for a while. Then for a while I wrote lots of professional resources and guides (mostly for the now closed Health Education Authority) - I love writing. Then I met Luk Joossens, who submerged me in tables of tobacco exports and imports and took two years to explain to me about subsidies, until I agreed to help him turn the data into accessible prose. Then Luk did the same thing to me with cigarette smuggling in 1995. Then the booklet the HEA asked me to write on the AHCPR smoking cessation guideline became national consensus based guidelines and eventually the basis of national policy. I doubt I'll ever do a more influential piece of work.
I guess the culmination has been writing a mass market paperback for the BBC on how to stop (published this week). It is a return to what I really like doing - writing - and it has almost brought me full circle -
back to helping individual smokers stop. I suppose ought to retire now. But as you know I now spend more and more time in Brasil. Working with smoking cessation specialists there is perhaps my latest challenge, and I love the country. I don't think I will ever leave the field entirely, just find new challenges all the time.
What you feel like adding :
That the real thing that has kept me going all this time (25 years) is the fantastic people. The tobacco control field has in it some extraordinary and committed people, people it is a privelege to know and work with. Quite a few have become very close friends, and sometimes I just sit in my study late at night and think what a wonderful time I have had for 25 years.
Thank you Martin for taking the time to be with us today.
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Philippe Boucher, cyberjournalist Web and Tobacco Control Consultant 9424 Windsong Loop Bainbridge Island, WA 98110 USA e-mail: boucher@globalink.org
Prepared by Philippe Boucher mailto:IslandErsk@aol.com
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