Philippe Boucher's Rendez Vous Ann McNeill
Rendez-vous with Ann McNeill
Health Education Authority (HEA)
By Philippe Boucher
Friday, January 14, 2000
Thank you Ann for accepting our ´ rendez-vous ª.
May I ask you to introduce yourself ?
I currently work part-time as a research adviser at the Health Education Authority (HEA - which will no longer exist after March 31st this year, see below) working mainly on smoking, but also do some work on other addictions. In addition, I am Chair of the WHO Partnership Project to reduce tobacco dependence and a member of the European branch of the SRNT (the Society for Research on Nicotine and Tobacco) Prior to the HEA I was at the Institute of Psychiatry within Professor Michael Russell's unit and worked predominantly on the development of dependence in young smokers.
As both my parents died of lung cancer (one was an active smoker, one passive), and the diagnosis was for them, and is still largely today, a death sentence, I also have a personal interest in preventing smokers from getting to that stage.
However, if the need remains for nicotine, I am also eager to ensure it comes in as safe a way as possible both to the person needing it and those around them!
First question : Can you tell us briefly about SRNT-Europe, how many people attended the recent conference (November 25/26), HEA' s involvement and what were its objectives?
The HEA and Department of Health here in England were very supportive of the idea to hold the second SRNT conference in London (a suggestion which originated from Dr Karl Fagerstrom) and agreed to be co-sponsors.
The Society for the Study of Addiction and WHO Europe also agreed to support the conference.
Nearly 600 people attended, including delegates & exhibitors from all corners of Europe, as well as many other countries in the world. There were two 'English'- oriented symposia - one examining the progress made with the government's new smoking cessation services & the smoking cessation guidelines one year after they were launched.
The other enabled delegates to preview the contents of the forthcoming Royal College of Physicians report on nicotine addiction in Britain which, inter alia, examines the anachronistic way tobacco has been regulated to date and makes recommendations for the future.
The third and fourth symposia were more 'European' and focused on novel biological targets for the treatment of tobacco dependence, and then invited oral and poster submissions.
The conference aimed to strengthen the presence of the society in Europe and it provided a forum for the exchange and dissemination of scientific information on nicotine and tobacco. I strongly believe that it is important to encourage new researchers to join the field, to encourage the link between science and policy, and to encourage the dissemination of new scientific findings to keep the tobacco issue in the public eye and I felt that the conference made positive strides in that direction.
2. Some countries are still reluctant to offer NRT products over the counter, without any prescription from a physician. Are there studies about the impact of OTC availability on smoking cessation attempts and successes?
The Cochrane review in this area indicates that NRT products double success rates compared with controls, irrespective of the intensity of adjunctive support.
There are now a few good studies looking at the specific issue of NRT OTC showing that it is effective (showing a similar doubling of effect in comparison to placebo) and safe.
Evidence from the US indicated that the switch to OTC status of NRT products resulted in increased uptake and use by smokers, and hence it was estimated, increased smoking cessation.
It will be interesting to see the effect of the switch of the 2mg gum in the UK to general sale. As well as access and efficacy, increased advertising of NRT products and its impact following the OTC switch should be considered.
3. New NRT products seem to come on the market faster and faster.
How are the consumers going to be able to choose between the patch, the gum, the inhaler, the spray, the pills?
Is it possible to determine what "works best" as a recent survey seems to imply?
There are not yet many trials comparing the products. The recent study by Hajek and colleagues in Arch Internal Medicine concluded that it was not possible to recommend one product versus others for overall efficacy, effects on withdrawal discomfort or perceived helpfulness. It still remains possible that they may be differentially effective for different target groups and there is evidence that the 4mg gum is more effective than 2mg gum for high dependent smokers, and that the nasal spray is more effective for high dependent than low dependent smokers. There may be individual differences such as some people do not like the taste of the gum, while others may find the patch irritates their skin.
Health professionals can provide advice as can consumer leaflets such as the HEA's leaflet on NRT.
Of course, NRT is only one pharmacological treatment, bupropion (zyban) is already on the market in some countries and others are being researched and seem likely to follow.
I welcome this diversification, providing the new treatments are proven to be effective, as it increases the range of choices for smokers.
4. The price of the nrt products still seems -to me- high. While several pilot projects targeting low income people will offer the products for free (that is -payed for by taxes-) what do you think would be an adequate pricing?
Friends I have in the pharmaceutical world tell me that the market (ie what the customer is ready to pay) determines the prices. They also tell me that big providers (like HMOs, the french social security, etc...) could obtain substantial discounts compared with today's average prices. Any comment?
It is difficult to balance the needs of businesses to produce products profitably with the need for the product to become more widely used and accessible to those who need it most. In England as in many other industralised nations, smoking is concentrated in lower income groups so it is very important that prices are kept as low as possible and there is evidence that price influences use. Personally, I would like to see prices as low as possible and any opportunities to obtain discounts should be grasped.
It will be interesting to see what effect the switch to GSL here has on prices.
The price of NRT is however much more crucial in developing countries as noted in the recent World Bank report. Together with colleagues at ASH and with the help of colleagues internationally, the issue of price of NRT vis a vis cigarettes is currently being examined... so watch this space.
If anyone reading wishes to include their country in this survey, all we need to know is the price of a packet of Marlboro compared with a 16 hr (please state the strength) patch and 2mg gum.
5. Your early research was around how quickly children become dependent on cigarettes, what developments have there been in this area and why do you now focus more on cessation/harm reduction?
This area remains under-researched, probably because of the difficulties of doing physiological research with adolescent smokers. People often talk about children smoking for social reasons, and adults because they were pharmacologically dependent, and it is interesting to know when the pharmacological kicks in (and why this differs in different people). The research I was involved in indicated that some young people show similar cotinine levels per cigarette to adults and similar signs of addiction to adults from very early on in their smoking careers. I am aware that there are now some exciting studies underway in the US which are exploring these issues further and which should be coming to fruition in the near future.
As to your second point, I think it will be difficult to dissuade young people from experimenting with cigarettes, but that doesn't mean we should give up trying. However, I do find it frustrating that with every Ministerial/ government official change the first issue we have to face is convincing them not to put all money in the 'preventing children from taking up smoking' basket.
The real (short-term) public health impact will come from adult smokers quitting and IF we can make some real significant changes in the harmfulness of cigarettes. The tobacco field is vast and daunting and it is easy to remain within one particular speciality but I think moving around does give one the benefit of different perspectives.
What you feel like adding :
Well, I always like to be optimistic. There are certainly exciting developments here in Europe with the long-awaited implementation of the advertising ban and now the possibility of having much stronger health warnings as well as the discussions around tobacco product modification.
The WHO Partnership Project is enabling us to seriously escalate our efforts in Europe in a number of areas. The WHO Framework Convention offers the best opportunity I have ever seen for real international impact.
As I mentioned earlier, the Health Education Authority (HEA) will no longer exist after March 31st this year, as a new organisation - the Health Development Agency - is being established 'out of the resources of the HEA'. The priority tobacco control will have in this new organisation is yet to be confirmed but already much of the smoking campaign work has been transferred to the direct management of the Department of Health.
I am at present deciding which of the options available to me I will pursue for the future, but I know I will remain in tobacco control. Let me finish by thanking you Philippe for giving me this interview and I would like to take this opportunity to thank the people I work with regularly, from many different countries and backgrounds, for their energy, enthusiasm, good humour and support over the years.
Thank you Ann for taking the time to be with us today.
Prepared by Philippe Boucher mailto:IslandErsk@aol.com
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