[Intl-tobacco] Minutes of Evidence: Examination of witnesses: PROFESSOR JOHN BRITTON, DR JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL O'NEILL

[Robert Weissman]

Minutes of Evidence: Examination of witnesses: PROFESSOR JOHN BRITTON, DR
JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL O'NEILL
Source: House of Commons, Wednesday, 2/2/00
Select Committee on Health Minutes of Evidence=20

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Examination of witnesses (Questions 308 - 319)  THURSDAY 9 DECEMBER 1999
PROFESSOR JOHN BRITTON, DR JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL
O'NEILL

Chairman

308. Thank you for coming this morning. We are most grateful to you for
the evidence that you have already submitted. I wonder if I could ask each
of you to introduce yourselves briefly to the Committee, starting with
you, Dr Mindell.

(Dr Mindell) I am a medical doctor. I have spent much of the past 20 years
looking after patients suffering from the effects of smoking and dealing
with the problems that causes their families as well. I have spent around
15 years being involved with tobacco control, including being Director of
a Cancer Prevention Campaign and I have published research on tobacco
control. I am trained in epidemiology and public health and I am a member
of the Faculty of Public Health Medicines and on their Policy Committee
and on their Cardiovascular Working Group.

(Dr O'Neill) My name is Bill O'Neill. I am a medical member of staff of
the BMA. I was previously a consultant in palliative medicine and prior to
that a general practitioner and I have, amongst other things,
responsibility at the BMA for our policies on tobacco control, including
an EC funded project called the Tobacco Control Resource Centre, working
with medical associations across the European region, encouraging the
involvement of other medical organisations in tobacco control issues.

(Sir Alexander Macara) Sandy Macara, immediate past Chairman of the BMA. I
have a particular continuing function in relation to tobacco control in
that I chair a tobacco action group jointly between the European region of
WHO and an organisation called the European Forum of Medical Associations
which is representative of the whole of the WHO European Region and this
activity is directly serviced by Dr O'Neill's Tobacco Control Resource
Centre which was set up in the Association when I was the Chairman. I am
also Chairman of the National Heart Forum. I am also anxious to remind
people that it is heart disease as well as cancer which is very
importantly involved in all of this.

(Professor Britton) I am John Britton. I am a consultant physician in
respiratory medicine and I work in Nottingham. I chair a group which
advises the Royal College of Physicians on tobacco related issues and I am
here today representing the College.

309. Could I begin by asking you, Sir Alexander, a point I have raised
with a number of our previous witnesses in earlier sessions which is that
we are now 50 years on from fairly significant evidence of the harmful
effects of tobacco on health. I mentioned in the previous session that we
had the Health Minister in 1954 speaking in the Chamber of the House of
Commons about the knowledge at that stage. Since this time we have had six
million deaths arising directly from tobacco use in this country. 120,000
people die every year. Why on earth has it taken so long, after all these
years of detailed knowledge, to address this matter seriously?

(Sir Alexander Macara) That is a very good question. There are a number of
starting points. The group of people who responded most rapidly and most
effectively to the evidence which our colleagues Richard Doll and others
were producing all that time ago were the doctors and other groups who
were able to understand and access the information followed suit.
Unfortunately that message has not been taken and applied to the same
extent by people as a whole. I think there are a number of reasons. One
must be that as doctors and scientists we are concerned to base everything
we do upon evidence and I think we have been excessively optimistic in our
expectation that when we have produced the evidence people will act on it.
By "people" I mean government, I mean consumers and I mean the tobacco
manufacturing industry. The fact is that none of these groups acted at all
in a sufficiently responsible manner to the evidence which we had
produced. Perhaps we were insufficient zealots, dare I use that word.
Perhaps we should have been stronger in our advocacy about the
implications of the evidence which we were producing.

310. There might be another interpretation and that interpretation was
implicit in Dr Yach's earlier evidence, which is that governments have
been corrupted by the tobacco industry. Would you apply that
interpretation to the UK?

(Sir Alexander Macara) I have been concerned for some time that a number
of Members of Parliament whom I have known, whom I have admired and
respected greatly seem to be prepared to take the Queen's shilling from
the tobacco manufacturing industry so that they receive retainers. They
did not have to declare this interest. I know that some of them are at
pains not to declare that interest. I would not claim that that was
corruption, but it does seem to me to be unfortunate.

311. Were these people who had some influence in terms of government
policy?

(Sir Alexander Macara) I certainly had the impression that the exercised
influenced beyond that which you would expect the average Member of
Parliament to do because they were obviously so very well informed by the
misinformation put out by the tobacco manufacturing industry who have
always, at least until very recently, sought to rubbish the evidence by
suggesting that it is a matter of controversy. There is no controversy
about it because the facts are clearly demonstrated.

312. I think you have been unduly modest about the efforts made by your
profession in respect of convincing politicians on the health dangers of
smoking. Do you have any view on the advice given by successive Chief
Medical Officers on the issue of smoking and health to successive
secretaries of state and successive governments and how that advice has
been acted upon or not acted upon and, if so, why it might not have been
acted upon in view of your earlier comments about connections between
tobacco companies and Members of Parliament?

(Sir Alexander Macara) The four countries of this kingdom are uniquely
well served by their Chief Medical Officers because there is no
equivocation about their position, they are the Government's advisers.
There are other countries, notably in Europe, where the Chief Medical
Officer is a political appointment and so he does not have the same
credibility. Our Chief Medical Officers have consistently sought to advise
Ministers at the time of all the implications of the evidence which the
professions have produced. I am bound to say that one gets the impression
that Government has been only too happy to use Chief Medical Officers to
distance themselves from the possible unpopularity of having to advise
people against something that they want to continue doing and where they
do not want to face the effect upon their health. Of course, the tobacco
manufacturing industry is only too happy to use both the CMOs and their
governments as a cordon sanitaire between themselves and the consumers. We
should have required the manufacturers to admit they are producing a
product which will kill half of all those who become addicted to it.

313. Looking back over the 50 years that we have talked about when all the
information was emerging, at what point do you believe that had we had an
open system of government and been aware of all these influences
government could have acted to save lives? At what point do you feel we
might have seen some much more significant action than has been taken over
this period?

(Sir Alexander Macara) I would put as the crucial date 1962 when Professor
Britton and my Royal College of Physicians produced its first report on
smoking and health. It could not have been more authoritative without
being authoritarian. It projected all the evidence in a thoroughly
convincing way and on which, as I have indicated, doctors at least acted.
If your predecessors in all parties had taken this matter up at that time
we could have saved millions of deaths and a great deal of preventable
disease.

314. Can I just focus for a moment on one or two of the issues that we
raised with the previous witness to do with the records of the various
tobacco companies. I wonder whether any of the organisations represented
here have accessed the documents of the depository in Guildford or are
aware of relevant information in those documents that has a bearing on
what we are looking at or a bearing on the concerns that we have just been
expressing about the amount of time it has taken to address this issue
politically?

(Sir Alexander Macara) Dr O'Neill has looked at this particularly.

(Dr O'Neill) At the BMA we have not made a direct attempt to get access to
the information because of its inaccessibility. What does one do when
faced with a warehouse of documents that are not adequately indexed? I
think Dr Yach has made the case very well for the need for electronic
access to that information and that point has been made by other witnesses
to this Committee. (Dr Mindell) I represent a very small organisation and
we do not have the resources to go there and try to look for needles in
haystacks.

315. I think one of the impressions we have from having met a number of
people in the States who were very interested in this point is that
collectively there is a lot of interest and a willingness to look at what
this archive contains and the implications of the archive on future
policy. Do you have any thoughts from your knowledge of that archive and
other archives that may have come to light on steps that we may be able to
take through this inquiry or procedures that we may bring about to move
forward on the knowledge of information that clearly was retained by the
tobacco companies going back many many years?

(Sir Alexander Macara) I do not know what my colleagues think, but I was
impressed by Dr Yach's replies to your questions about this and, in
particular, the way in which electronic access might assist us here.
Clearly we do need some assistance to enable the basic work to be done.
When we do have some information then we can proceed.

(Professor Britton) Whilst the contents of archives, such as the Guildford
archive, will be fascinating in the insight that they provide to what has
gone on in the past, I would say that in many other ways we have perfectly
adequate evidence to make sensible public health policy for the future
without spending hours and years trawling through dusty archives.

Mr Austin

316. I think Dr Yach was suggesting that $2-4 million may be the cost of
accessing that information. Do you feel that that would be public money
well worth spending?

(Sir Alexander Macara) It depends on whether one is thinking in absolute
or relative terms. It may not seem to be as useful as other measures that
might be taken, but in absolute terms one would have thought it is a very
small amount of money to find as against that which is involved in the
whole tobacco manufacturing market.

Mr Gunnell

317. You would think that most of the health consequences of smoking are
known beyond reasonable doubt. Where would you say there is still genuine
scientific controversy about them? Do you not agree, since there is no
doubt about the issues and the consequences of passive smoking and that
there ought to be action taken by Government on a very firm basis in
connection with that, that they should be prepared to legislate and not to
rely on the voluntary agreements of companies involved?

(Professor Britton) In terms of active smoking, there is no doubt that
smoking causes lung cancer and a long list of diseases which I think
probably everyone here is familiar with. What is not known is how long
that list is and which associations have not yet been detected. In terms
of passive smoking, I think there can be no question that passive smoking
is associated with an increased risk of lung cancer, respiratory symptoms
in young children, and passive smoke exposure of the unborn child with an
increased risk of death in the utero. This is imposed on children by
smoking adults, which I think is unacceptable in public health terms.

318. Do you think that a much firmer line should be taken by Government to
make it clear that they are not going to rely on the voluntary agreements
of the companies involved or the restaurateurs or public opinion anymore?

(Professor Britton) I want to come back to the question the Chairman asked
earlier about who is at fault for the failure of public health measures in
tobacco controls. In my view a great deal of fault lies in Government for
not grasping the obvious facts and acting on them. The voluntary
agreements are part of the reason that tobacco control is still so low.
Although it is better than many countries, it is inadequate in this
country. 50 years have gone by because of prevarications by Government.

319. So that would indicate that it should be made compulsory through
legislation, would it not?

(Professor Britton) Yes.

(Sir Alexander Macara) Which could well apply to workplaces because just
as we should be protecting children, we need to protect workers and not
every employer is as responsible as they might be in that regard.

(Dr O'Neill) I think that is unquestionably true. I think one should
distinguish between voluntary agreements with the tobacco industry and
voluntary agreements with other groups and one would not want to criticise
the restaurant and pub industry for the initiatives they have taken, but I
think one has to draw a clear distinction between groups such as this ,and
the tobacco industry, based on the behaviour of the tobacco industry over
the last three or four decades.

=A9 Parliamentary copyright 2000 Prepared 2 February 2000

Select Committee on Health Minutes of Evidence

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Examination of witnesses (Questions 320 - 339)  THURSDAY 9 DECEMBER 1999

PROFESSOR JOHN BRITTON, DR JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL
O'NEILL

Mr Austin

320. I was at a meeting a few nights ago where one of the physicians was
saying that the incidence of heart disease was significantly increased by
environmental tobacco smoke and I see you left that off your list.

(Professor Britton) There is a long list of diseases associated with that
and I have mentioned some of them and heart disease is another.

Audrey Wise

321. What do you think of the tobacco company's approach to medical
science both over the last few decades and currently?

(Sir Alexander Macara) They have been very flattering, have they not? All
the evidence now is that they were at pains to repeat the work which had
been done by independent scientist; in fact, they employed other
independent scientists to research the effects of tobacco. The evidence
now is that their own research has confirmed the evidence which had been
produced and then they appear to have been at pains, as we now know, to
conceal this confirmation. You may say that they were highly flattering in
that they recognised the need to repeat the work no doubt hoping to be
able to find loose threads that they can pull to unravel the whole fabric
of the argument against them. I am afraid in historical terms they have
shot themselves in the foot because they have now been revealed to have
been responsible for deliberate suppression of the facts and
misrepresentation about the facts which had been produced.

322. I am interested in some of your phases you have used, such as "as we
now know" and "have now been revealed" and that would not have happened to
the same extent by any means without people rooting about in dusty
archives. I wonder if you would care to comment a little bit more on that
because I have noticed in the BMA evidence you have a list of tobacco
company's failures, that is failure to inform of the dangers of smoking
and failure to reduce the harmfulness and failure to disclose the contents
and so on. Failure is an interesting word in that context because failure
suggests you have tried to do something and you have not quite managed it.
I would rather say that they have tried to mislead rather than failed to
inform and I wonder if you would care to comment on the thrust of your
evidence there. Is your own evidence strong enough? We hear that
governments are weak.

(Sir Alexander Macara) We do not hesitate to use pretty strong language on
occasions because we feel it is our public duty to promote public health
and to protect our patients, but sometimes we want to assume that there
might just be some intention of good faith on the part of the tobacco
manufacturers. It may be that they felt their responsibility was to
protect their markets and their shareholders and their employees, which is
a very worthy matter if you are an employer or a shareholder out with the
responsibilities to the public health. They might have thought that was
your responsibility as Parliamentarians and ours as medical scientists. We
were restrained in the use of that word(failure), but I certainly would
not disagree with the view that it is hardly strong enough.

323. You have mentioned your disappointment at the failure of people to
act on warnings about health damage. It does seem rather remarkable that
there has been quite a lot of knowledge and suspicion about damage to
health. I wonder if you would care to reflect and discuss the issue of the
public mood in connection with this. We went to the USA last week and I
picked up a very strong feeling of anger which is missing here. People are
warned and there is a certain amount of anger on the issue of the rights
of the non-smoker, but because of the disclosure of the tobacco companies
misleading and manipulating people in the USA and ripping off and denial
and lying there is a considerable mood of public anger. Do you not think
that if people become angry about being manipulated they may be more open
to public health messages?

(Dr O'Neill) The reality is that in this country it is estimated that we
have been spending about =A310 million per year getting across the health
message as opposed to probably ten times that amount of money being spent
by the industry. There is no doubt that in the United States the series of
cases that have gone to the courts has done an enormous amount to
highlight the dangers associated with smoking and, in particular, to
highlight the behaviour of the industry. The British Medical Association
publicly supported the group action that has been taken on behalf of the
52 patients with lung cancer in this country through the courts, not
because of the probably relatively paltry sums of money that patients were
going to get at the end of the day, but because of the information that
would be disclosed in court, because for the first time the truth would
see the light of day and we certainly regretted the collapse of that case.

324. I think some of us individually might agree with you on that. Does
that not make it even more important to ensure that the truth sees the
light of day?

(Dr O'Neill) We believe that until the industry are put in the dock in
this country, whether it be in front of a Committee such as this or some
other forum, we will not have the full truth, and nor will the public, of
what has actually gone on over the last 20 to 40 years.

325. The Chairman asked you whether you had attempted to access the
Guildford depository. Are you aware that if you did try tomorrow you would
almost certainly be told, "I am sorry, nobody can get in for at least the
next four months because we are booked up"?

(Dr O'Neill) We are absolutely aware of that.

326. Perhaps there is some merit in looking in dusty archives. If they are
so keen on keeping it secret, should not all of us be rather keen on
getting it revealed?

(Professor Britton) I would not wish to be misinterpreted=97

Chairman

327. I think you might have been, Professor.

(Professor Britton) On the one hand it is important to establish the truth
of events that have gone by if that influences public mood in terms of
engendering a sense which I, too, have detected in the United States of
betrayal by an industry, but the facts of the health arguments have been
with us for nearly 40 years and perhaps it is appropriate to look to the
future rather than the past in terms of resolving this problem.

Audrey Wise

328. But that implies, does it not, that they have all changed their
spots?

(Professor Britton) Who has?

329. The tobacco companies.

(Professor Britton) Effective public health measures to do with smoking
will come from legislation.

330. Are you conscious of the scientific and technological precision and
power which we and health authorities in general are facing? We were told,
for example, by the US Food and Drug Administration that the scientific
knowledge and technological power of the tobacco companies enables them to
ensure a nicotine dosage of such precision in every cigarette packet that
outweighs the capacity of the pharmaceutical companies to ensure the
dosage they want in nicotine replacement therapy. That is the level of
scientific and technological power that we are facing. Does that suggest
that this is all to do with past attitudes of the tobacco companies?

(Professor Britton) Tobacco companies produce very sophisticated products,
I do not think anybody here would argue against that. Cigarettes are
nicotine delivery devices, that is what they are created to be. Salbutamol
inhalers are broncho-dilatory devices used by people with asthma to treat
their asthma. They are also very sophisticated devices. The asthma device
is legislated to very tight standards of safety and disclosure and
cigarettes are not. That is a failure of legislation, not of technological
advance.

(Sir Alexander Macara) It is even worse than that because we have evidence
of the manufacturers deliberately putting additives about which we simply
do not know enough into tobacco in order to increase the absorption of
nicotine from the bronchi. They even use chocolate for this purpose. I
have no doubt if they put on the packet that their product contained
chocolate it might be a very clever marketing device. I think they ought
to have me as a consultant. They put it there in order to increase the
absorption of the nicotine in the cigarettes. That is absolutely right,
they are using the results of their own research to potentiate the
addictive part of their product.

331. That does suggest that when we talk about manipulation by the tobacco
companies it is current as well as past.

(Sir Alexander Macara) There is no question about that. I do not know
whether my colleagues would like to add anything.

(Dr Mindell) I think what Professor Britton was saying is that if
governments want to act to introduce comprehensive legislation to control
tobacco they can do that on the basis of what is already known without
necessarily having additional information from the archives. However, the
archive material is important partly because of increasing the public's
awareness and acceptance and demand for such legislation but also to avoid
the tobacco industry knowing things that Government does not when the
legislation is worded and that is why I think that continuing exposure of
current research and other internal memos would be important as well.

332. I am very anxious that Professor Britton should not be misinterpreted
by anybody else.

(Sir Alexander Macara) So are we.

333. We had an exchange with the Department of Health on this when they
came to give evidence and some of us were surprised to find that there is
no assessment of the real public health consequences made about additives,
additives just get approved. We were told, "Well, we don't look at whether
they are dangerous because they are used in such small quantities". I did
point out that the purpose of some of them was to make the tobacco more
palatable and more attractive. You could use an analogy with cocaine: you
use spices and salt in very small quantities, but it has a very big effect
on whether you want to eat it or not and the same thing could apply to
cigarettes. It may be that this message goes into the Department of
Health. Would you like to add your comments on this particular aspect?

(Sir Alexander Macara) Dr O'Neill certainly will. I would just add that
strychnine is very effective even in the very smallest possible doses.

Dr Brand

334. Are you suggesting that we add that to tobacco and shorten the course
of events?

(Sir Alexander Macara) I can think of some people who might think of it as
an advantage.

(Dr O'Neill) The reality is that we regulate our food, we regulate our
drugs and tobacco does not fall into either category. The majority of
additives in food are regulated. There is absolutely no reason why
additives in tobacco and other constituents in tobacco should not be
regulated and until we have effective regulation we are unlikely to see
any real change.

335. Can I pick up that point on regulation, Mr Chairman, because we put
the same point to the Department of Health, which is that there does not
seem to be any consumer protection for people that smoke. The feedback I
think we had was, "Well, why should there be since it is such a nasty
habit anyway which kills half its consumers", and I think there has been
an absolutist attitude towards smokers which is beginning to shift a
little. I recognise in the evidence we have received from ASH and in the
written evidence from the Royal College of Physicians that people are now
talking about safer cigarettes and the regulation of products. I do not
want to be too historical, but have we not been at fault in saying that we
really cannot cope with anyone that smokes at any time?

(Dr Mindell) I will make two points in response to that. Firstly, as
regards regulation, we have the bizarre situation at the moment that
nicotine delivery devices that deliver only nicotine are highly regulated,
but if they deliver thousands of other toxic chemicals as well then they
are not regulated. You should remember that almost all smokers start
smoking when they are children, when they are far too young to be
concerned with dying when they are 40 or 50 rather than when they are 60
or 80. Most smokers want to give up but they are addicted. When you
interview teenagers you find that most of them say, "Yes, I smoke now but
I'm going to stop", and they find it very difficult to do so. Some find it
extremely difficult. Some have managed to stop. We know that there are
still a very large number of people who would like to stop smoking. There
are a lot of inequalities in this country, not so much in who starts
smoking and not so much in who wants to stop, but particularly in those
who succeed in stopping smoking and that is where the biggest divide is.

Chairman

336. So it is a social class divide, the implication being it is middle
class people who can stop and working class people who cannot, is it?

(Dr Mindell) Those in the poorest circumstances may not be able to afford
the additional benefit of nicotine replacement or they may have so many
other stresses in their life that the difficulties of stopping smoking are
more than they feel they can cope with. The two most important things in
stopping smoking are the desire to want to stop and to believe that you
can stop and that you can exist without cigarettes and this is why all
these other things that we have also been touching on, whether it is price
rises or smoke free areas, are also important for smoking cessation
because it can encourage people to exist as a non-smoker.

Dr Brand

337. Is it not very important that we have access to the information that
clearly the tobacco companies have to their knowledge that allows them to
produce products that encourage people to continue?

(Professor Britton) It is clearly important to know what is in cigarettes.
The gains in public health that are to be realised have to do with
legislating against what is there and what is likely to be produced in
response to legislation. A point one of my colleagues made was that having
a fuller awareness of what is known about tobacco technology is crucial to
the phrasing of such legislation and the formulation of legislation, but
the public health gains can be made without getting too obsessed with what
is actually in the cigarette.

Mr Austin

338. Can I deal with what is in the cigarette. In a previous session, we
had evidence that suggested that a large number of smokers actually
believe that smoking low-tar cigarettes or lights or milds or ultra-lights
are less harmful, but we have had evidence that because they need to get
their fix, they engage in compensatory smoking, so that more virulent
forms of cancer and adenocarcinomas have been increasing as well, which
brings me on to whether there is such a thing as a safer or a less deadly
cigarette. Obviously the Government's health campaign is that obviously,
we all agree, the best thing is not to start and if you do start, to stop,
but even if the Government meets its targets of getting people to quit
smoking, in ten years' time a quarter of all adults will still be smoking
and overwhelmingly in the poorest groups in society. Is it possible to
reduce that health impact on those who continue to smoke by requiring, by
legislation, changes to the content of cigarettes, to remove selectively
or reduce chemicals which we know contribute to cancer and lung and heart
disease?

(Sir Alexander Macara) It would be one contributory factor, but on its own
it would be of limited value.

(Professor Britton) I think there are at least two issues raised by that.
One is genuine harm reduction in smokers who cannot give up and that is
obviously as desirable as any other harm reduction intervention. One of
the problems, as I see it, with the whole low tar strategy is that what it
may well do is encourage people to continue smoking, believing that they
are smoking a safer product, when in fact they are not. I think it is a
very difficult judgment to make between something that genuinely reduces
harm for those people addicted to the products and who cannot give up from
that product which actually increases harm by extending the market for the
product.

(Sir Alexander Macara) There is no such thing as a safer cigarette; there
are only less dangerous cigarettes.

(Dr O'Neill) I think we need to be very careful with the terminology
because there is no doubt about it, that the industry has scored an
enormous goal with the concept of low-tar and light cigarettes. I think we
need to make sure that that does not happen again. Having said that, I
think we do need to acknowledge the fact that even if we meet the targets
which are set, 24 per cent of the population will still be smoking in ten
years' time, and whatever can be done to lessen the burden of disease in
that group of people clearly is very important, but absolutely accepting
the point that Professor Britton made, that we need to be careful that
that then does not fudge the whole issue, that we do not find we are
actually discouraging people from giving up cigarettes by implying that
there actually is a safe product. It is quite clear that there cannot be a
safe product in the way in which we understand this product. There are
clearly opportunities for looking both at additives, for looking at other
constituents in cigarettes, and you have already had evidence about the
possibility of lowering nitrosamines in cigarettes and lowering carbon
monoxide levels in cigarettes which would respectively have an effect on
the burden of cancer and indeed heart disease. I think those avenues
should be pursued, but I think we need to make sure that we are actually
getting at the truth we have all of the information and that we do not
allow the industry further opportunities to score points on this issue.

(Sir Alexander Macara) And we do not allow the industry to try to paint
those of us who are anxious to help the victims of their successful
marketing, that we do not allow them to paint us as nannies or as health
fascists because this is the obvious ploy now which I think in part
answers Dr Brand's question as to why are we not doing enough to protect
smokers. I sense, Chairman, and I am sad to say this, but I sense with
your colleagues, within government generally, within the Department of
Health a terror about being accused of being nannies or health fascists
when all we are trying to do is the job you have been elected to do and we
have a moral duty to do which is to stop these people from killing people
to the extent that we possibly can.

Chairman: I think I will bring Simon Burns in and he is not called "Burns"
for nothing!

Mr Burns

339. If there is no such thing as a safer cigarette, but there are only
less dangerous cigarettes, then how much do you think that
nitrosamine-free cigarettes are less dangerous than conventional
cigarettes?

(Professor Britton) In theory, nitrosamine-free or nitrosamine-reduced
cigarettes should be safer than conventional cigarettes, but I think that
there is a risk with initiatives such as that, as with the low tar
initiative which dates back 30 years, to assume that because it seems
logical that something will generate a health gain, it actually will. What
we have seen with low-tar cigarettes is a change in the way that people
smoke, the products that they smoke and a change in the disease profile
that emerges from it, so the assumption that reducing tar will produce a
health benefit may have actually backfired by just changing the profiles
of cancers caused and by people compensating and finding a way around the
measures that have been made to reduce the toxicity of the cigarette, so,
in theory, yes, reducing nitrosamines, reducing tar in general should
help, but, in practice, you do not know it does until you have introduced
it and tried it, and if that perpetuates smoking in society for another 30
years while you decide whether it has worked or not, you have lost.

=A9 Parliamentary copyright 2000 Prepared 2 February 2000

Select Committee on Health Minutes of Evidence

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Examination of witnesses (Questions 340 - 359)  THURSDAY 9 DECEMBER 1999

PROFESSOR JOHN BRITTON, DR JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL
O'NEILL

340. We were in the United States last week and we met up with a company
called Star Scientific who have got this patent to take it out of
cigarettes. Do you think though that if it were to be shown that that is
infinitely less dangerous, then it should be made compulsory on the basis
that you are not going to get everyone to give up smoking, so you may as
well have a product that is the least dangerous one as possible on the
market?

(Professor Britton) Well, I think that cigarettes need to be regulated, as
I said earlier, like any other drug-delivery device, but you are starting
from a situation where instead of a new drug being introduced into the
market and having to demonstrate its safety, you have an established
product in the market whose market share we want to reduce, whose coverage
we want to reduce, and it is important that tobacco manufacturers are made
to do as much as they reasonably can to ensure the minimum danger of their
product in a background of regulation which has the target of a smoke-free
society in a reasonable period of time.

(Sir Alexander Macara) You probably know that the Council of Ministers in
the EU, which was attended by Gisela Stuart of the UK, in its meeting on
the 18th November supported the proposal from David Byrne, the
Commissioner for Health, that there should be EU-wide limits on the tar,
carbon monoxide and nicotine content of cigarettes, so there is at least a
start there within the EU.

341. But picking up on that point, do you think that consumers have been
misled in the recent past by the emphasis on lowering nominal tar use?

(Sir Alexander Macara) I do not think there is any doubt that they have
been misled by receiving part of the truth and not the whole truth. It is
sometimes more damaging to have part of the truth because you do not
realise what you do not know, and I think it would be fair to say that in
recent times the industry has begun to admit not its complicity in
concealing facts for so long, but to admit that there is a link between
smoking and-ill-health. They are still trying to deny the nature of
addiction, so at least perhaps they still deny that tobacco is addictive,
but they seem, I think, to be more concerned to fend off the possibility
of litigation than to be honest in freely informing their consumers about
the risks.

342. Am I right in thinking, and I just have this in the back of my mind
from some people we were talking to in America, that with regard to
lower-tar cigarettes, the light cigarettes, the medical evidence is now
showing that although people believe that by smoking lights, they are in
fact enhancing their health prospects, but in fact the illnesses have
shifted or different strands have developed, particularly with heart
disease, because it is a different product, so in fact it is not safer and
it is a myth that if you buy lights, you are actually going to be
improving your health prospects? That is correct, is it not?

(Sir Alexander Macara) That is absolutely correct and it reinforces the
point made earlier about the importance of language; that to suggest that
something is light means it is not heavy and, therefore, it is not
dangerous, and we do have to be aware of this.

(Dr O'Neill) There are two things here because not only has it not lowered
the burden of disease, but it has also changed the distribution of
disease, which is the point Professor Britton made a few moments ago.

343. So do you think that you can take a logical conclusion from that,
that all the publicity about the safer cigarette, whether it be by taking
out certain elements in cigarettes or by having lights or lower-tar ones,
is in fact leading to encouraging some people to smoke or to continue to
smoke who would not otherwise have started smoking or who would have tried
to stop smoking with the painful withdrawal symptoms that that entails
rather than going on to what they believe is a safer cigarette?

(Sir Alexander Macara) Yes.

344. So if the answer is yes, do you think then that we should do anything
to stop that sort of marketing of cigarettes that creates the impression
that they are safer or better for you?

(Sir Alexander Macara) Yes. In fact we believe that you should stop all
advertising and sponsorship and, as part of that, misleading statements.
Marketing equates with advertising and sponsorship and we think that it
should all be stopped. After all, we do not allow heroin, for example, to
be advertised and freely available to the public. There is nothing much we
can do to stop cigarettes being available in a free society, and perhaps
if we had known what we know about them now when Walter Raleigh brought
tobacco across that "damn ditch", as Perry Worsthorne once described it,
we would have prohibited its consumption a very long time ago, but we did
not.

Dr Brand

345. James I tried.

(Sir Alexander Macara) Yes, James I did try, but then he was a Scot in
England!

Mr Austin

346. It was James VI, I think.

(Sir Alexander Macara) It was James VI and I.

Chairman: We are going slightly off beam now.

Mr Burns

347. I just wanted to take us slightly off beam as well because something
has just occurred to me, arising out of something you said earlier.
Forgive me for asking, but when did you leave the BMA?

(Sir Alexander Macara) I was Chairman for five years.

348. When did that finish?

(Sir Alexander Macara) Seventeen months ago in July 1998.

349. Do you think, given your experience in that role and your liaison and
dealings with the Department of Health, that it is surprising to you that
the independent Chief Medical Officer would not have given the Government
of the day his advice on, say, for example, making exceptions to Formula
One sponsorship?

(Sir Alexander Macara) One would be speculating of course=97

350. Indeed.

(Sir Alexander Macara)=97but I would be surprised if Sir Kenneth Calman had
ever withheld any good advice=97

351. I was thinking more of the current Chief Medical Officer.

(Sir Alexander Macara) I would again not speculate, except that he was my
student.

352. So you do not know how he operates, his modus operandi?

(Sir Alexander Macara) Yes. He was a good student and I would expect him
to have demonstrated that. The Chief Medical Officers, as I keep
emphasising, there are of course four in our devolved kingdom, I would be
very surprised if they have not given good advice whether solicited and
welcome or not.

353. Even if they had only been in place for two weeks?

(Sir Alexander Macara) Or perhaps particularly because they have to
establish their position, and their credibility depends upon being seen to
give the best advice without any political consideration.

354. Of course. That is fascinating. Would it then come as a surprise to
you that he told me that because he had only been in post for two weeks,
he had never given any advice to the Government on Formula One and
sponsorship?

(Sir Alexander Macara) No, it would not surprise me if he had not been
given the opportunity or if he had judged perhaps that ministers at that
particular time had a great deal more on their minds, and I assume that
what I said at the proper opportunity would have been=97

355. I am sorry, but I thought you said a minute or two ago that knowing
the man, regardless of whether he was asked or not, he might have given a
view.

(Sir Alexander Macara) Yes, but a CMO, no more than any other civil
servant, they are civil servants, cannot very well bully ministers and
force them to=97

356. No, but they can give advice surely in that capacity without bullying
by carrying on if the advice is not taken.

(Sir Alexander Macara) I was assuming there would be the appropriate
opportunity for them to give advice=97

357. So would I.

(Sir Alexander Macara)=97whether welcome or not.

Dr Brand

358. Chairman, can I help SirAlexander. Would it not be true to say that
the Minister that the Chief Medical Officer would have been talking to,
the Public Health Minister, was not actually involved in making the
decision on Formula One?

(Sir Alexander Macara) I imagine that so far as Formula One is concerned
we all have something of a problem because I think we could all have
handled the matter better and the political sensitivities, I think we all
understand the political sensitivities, and it is highly unfortunate, but
I would take the view that we should go on from that experience to learn
that we cannot make exceptions in terms of essential public policy.

Chairman

359. I think you will be aware of the comments of this Committee on the
Formula One issue, Sir Alexander.

(Sir Alexander Macara) I can imagine, Chairman.

=A9 Parliamentary copyright 2000 Prepared 2 February 2000

Select Committee on Health Minutes of Evidence

------------------------------------------------------------------------

Examination of witnesses (Questions 360 - 379)  THURSDAY 9 DECEMBER 1999

PROFESSOR JOHN BRITTON, DR JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL
O'NEILL

Mr Austin

360. To take the cigarette as a nicotine-delivery vehicle, it has
certainly been suggested that the tobacco companies have tried to define
the addictiveness of nicotine as a habit and I have to say I did make a
comment in the earlier session that even the Tobacco Advisory Council seem
to use the words "dependency", "habit" and "addiction" almost
interchangeably. There is this sort of suggestion that it is a habit a bit
like shopping on the Internet, that it is a little damaging. Would you
like to tell us something about the medical view of the nature of the
addictiveness of tobacco?

(Professor Britton) Nicotine "addictiveness" and "dependency" are words
that can be used interchangeably for practical purposes. The addictiveness
of nicotine is determined partly by the drug itself and partly by how it
is delivered.Cigarettes deliver nicotine in a very rapid dose into the
arterial blood to the brain and it is that form of delivery, plus the drug
itself which is important. In that circumstance, the evidence that the
College has recently put together in a report which our submission to the
Committee is based on is that nicotine is as addictive, on a par in terms
of addictiveness to heroin and cocaine, so to the major drugs of abuse and
harm in this society, illegal drugs of abuse.

361. When did you reach the conclusion or when did the medical profession
generally reach the conclusion that nicotine was addictive?

(Professor Britton) There is reference to the fact that nicotine may well
be addictive in the 1962 first Royal College of Physicians Report. I think
that the bulk of evidence that our current report relates to has come
through over the last ten years or so, between the 1980s and 1990s. I
think that is right.

362. You have indicated that there is a comparison with other drugs of
dependence, what are often described as "hard drugs".

(Professor Britton) Yes.

363. I think some of us might think given the nature of the evidence that
nicotine should be classified as a hard drug.

(Professor Britton) Yes, it should be.

364. What objective research has been shown to demonstrate that nicotine
is this powerful addictive drug on a par with those other drugs?

(Professor Britton) There is extensive work in animals showing similar
levels of drug-seeking behaviour for nicotine as for cocaine and heroin.
The ranking of relative addiction varies according to the experimental
system used. Drug behaviour in humans, dependency is defined in relation
to certain set criteria from the American Psychiatric Association and from
the ICD, the International Classification of Diseases definitions.
Nicotine meets those criteria just as clearly as do other hard drugs of
addiction and I do not think there is much distinction to draw between
them. The main difference is firstly that nicotine does not produce
intoxication and perhaps has not been seen historically as such a problem
in society, and secondly that it is legal.

365. So apart from the fact that it is addictive, the damage is the
delivery vehicle in which it comes?

(Professor Britton) In theory, there are some potential ways in which
nicotine may be harmful in its own right. They are very, very small
effects. In terms of the total damage done by cigarette-smoking, it is
minimal, negligible in relation to the harm done by the vehicle.

Dr Brand

366. Given the addictive nature of nicotine, do you think we have got the
policy right in supporting people that want to withdraw from this drug?

(Sir Alexander Macara) I think we have got the policy right in wanting to
help people.

367. That was not the question.

(Sir Alexander Macara) Thank you. I hoped the question was: are we doing
enough? The answer is no, of course we are not. Smoking Kills, which was
launched almost a year ago, was a very good start in a statement of
government commitment to assist people to quit smoking. What we
particularly regretted was the restricted nature of the specific support
which could and should be given through nicotine replacement therapy and I
know that Professor Britton in particular has strong feelings about that;
we all do. It seems very regrettable that the ability for doctors to
prescribe for their patients an effective drug which would really
effectively help them is so restricted.

368. How long, this is to you or Professor Britton, would you normally
think there was a need for nicotine replacement during the withdrawal
phase?

(Professor Britton) The evidence is that nicotine replacement has most of
its effects within the first few weeks of treatment and after about six
weeks or so there is little incremental extra benefit.

369. So if you were going to make a recommendation to the Government, you
would say that rather than having a week's supply to a very limited number
of people in health action zones, you would make six weeks' supply
available presumably in weekly bits so that people need to keep in contact
with their=97

(Professor Britton) There are two points there. The first is that there is
limited supply to a limited number of people in health action zones.
People in health action zones qualify for nicotine only if they qualify
for free prescriptions, so in fact the coverage of the availability of
nicotine replacement therapy at present is less wide than the White Paper
perhaps implies.

Chairman

370. So it is people on free prescriptions in health action zones for a
week?

(Professor Britton) Yes, for a week. It is not people just living in
health action zones, so in terms of postcode prescribing, which was the
bite on the radio last night, health action zones are a particular example
of how it should not be. You need to be living in the right postcode and
to have free prescriptions to get one week of nicotine.

(Dr Mindell) I think even then you actually have to be referred to a
specialist smoking clinic.

(Professor Britton) Yes, so there are many barriers to getting it. The
second thing is that most people who are going to fail have failed by
about a week and, therefore, if you make supplies of nicotine conditional
on success up to a certain point, there are enormous potential savings to
make. To give every smoker who says "I would like to give up smoking" six
weeks of nicotine over the counter now would be very wasteful.

Dr Brand

371. You believe that there is a distinct role for nicotine replacement
therapy as part of a Stop Smoke programme?

(Sir Alexander Macara) The important point is as part of, is it not?

(Professor Britton) Nicotine replacement therapy works if you buy it over
the counter, it just may not work quite so well. Nicotine replacement
therapy is one of the most cost-effective medical treatments available. It
is the only one that is effective, that I am aware of, that is not
prescribable.

(Sir Alexander Macara) It will work particularly well within the context
of the general practitioner or health adviser supporting and counselling
the individual, which is why it is important that general practitioners
are able to prescribe it.

372. The Glaxo Wellcome drug, Zyban, is that something that should be
evaluated as a matter of urgency by the National Institute of Clinical
Excellence?

(Dr O'Neill) It is very difficult to measure the word "urgency" in the
context of the National Institute at the present time when there are so
many things on the agenda. There is no doubt about it, the drug needs to
be evaluated and a decision needs to be taken on whether or not it is
going to be available in this country.

(Professor Britton) The drug clearly works, as nicotine replacement does.
Smoking kills 50 per cent of smokers and here is an effective treatment
which will reduce that risk, it seems stupid not to take it on. In terms
of the economic arguments, medicine embraces many incredibly expensive
treatments. Drugs that lower blood fat levels are a classic example. An
estimate in the press last week was of about =A35,500 per life year saved
and smoking comes out at between =A3200 and =A3800 depending on how you
deliver the service. It is remarkably good value. It is quite low tech and
a bit simple and I think that is perhaps why it does not get quite the
kudos of other interventions.

(Sir Alexander Macara) There is just one point I would like to clarify. I
expect Dr Mindell has another point. I would not like it to be thought
that we are being critical of the concept of Health Action Zones. It has
to be a good thing that there are opportunities there to target those
people most in need of help and support of all kinds. It is also a good
thing that nicotine replacement therapy will be evaluated. The important
point Professor Britton was making was that the timescale in which that is
to be permitted is far too short to produce the results that we would wish
to see. I am sorry, I cut across Dr Mindell.

(Dr Mindell) I wanted to add that smoking cessation support is really in
two parts, one of which is what we were talking about just now about
measures to help those smokers who have decided that they would like to
quit and to help them at an individual level, but the public health policy
level that requires Government action, apart from support at this
individual level, is equally important, measures like banning all forms of
tobacco promotion, increasing the price consistently above inflation,
preventing smoking in public places. All these types of approaches are
just as important in encouraging smokers to try to stop, in enabling them
to remain stopped and in reducing the number of adult smoking models that
influence young people.

(Dr O'Neill) The other thing we must add to all of this is the fact that
clearly the case for nicotine replacement therapy is proven. Having said
that, we still have a situation where many people have contact with health
professionals and are not asked something as simple as their smoking
status. I know you have had evidence submitted here of the work of
Professor Fowler in the late 1970s and early 1980s who, as a general
practitioner, advocated the fact that every general practitioner should
ask a patient about their smoking status, should give them brief advice
and possibly add nicotine replacement therapy to that. That has been
demonstrated to be effective. I think there is a case to answer for every
doctor, nurse and health professional in the country, whether they are
asking patients about their smoking status, whether they are advising them
about the benefits of stopping smoking and, indeed, what doctors, nurses
and others are doing themselves about their smoking behaviour. I think
that is a very important message that we must get across.

Chairman

373. Could I come back to regulation. Dr Mindell, you described broadly
your thoughts on what should be included in the regulation. I do not know
whether your view collectively is that that regulation should be national
or EU-wide. There is another point I want to make before I raise another
issue about the "light" cigarettes, a question which Sir Alexander raised.
What are your views on the actual regulation of nicotine and whether
nicotine can be effectively regulated out of these products in some way?

(Dr Mindell) Can I start by saying that in tandem with deciding you can
regulate nicotine out, or whether you should regulate it out, you need to
know what you are regulating. The measurement of nicotine and tar is
crucial. At the moment we have a completely flawed system. Low tar, low
nicotine cigarettes actually contain almost identical amounts of tar and
nicotine to not low tar ones. The difference is that when you smoke it, as
smoked by those machines that are designed for these regulatory purposes,
the amount of tar and nicotine is much lower than in the earlier designs
of cigarette. That is not the same as when a smoker smokes it. As we have
already heard, people who change from medium or high to low tar and low
nicotine cigarettes inhale more deeply and leave a shorter stub because
they are trying to maintain the same nicotine fix that they were getting
on the previous cigarette. The other thing that has become known more
recently is the way that tar and nicotine is lowered is through
microscopic holes which happen to be where a smoker's lips or fingers
would be and when those holes are covered you do not have this lowering
effect. One of the things that has to be done is to develop some form of
measurement that actually measures what is important rather than measures
what customers are currently being told. Personally I am not bothered
whether these regulations are at the EU or at the national level. The
advantage of the European level is that they will be of benefit to more
people. Whichever is easier to implement. Having them at a national level
does not preclude, and may even strengthen, European moves to have them
across Europe. I do not think that this Government should necessarily wait
for European Directives. On the other hand, if that is considered a better
or faster or more comprehensive way then that is fine.

374. Coming back to the issue of low tar, so-called "light" cigarettes,
Sir Alexander made a point about completely banning advertising and
marketing. Presumably you would be against a packet having somehow a claim
in the title that was low tar or implicitly less harmful, would you?

(Sir Alexander Macara) I think we do have to look at the language, the
words that are used. I think we are entitled to restrict the words that
can be used in the marketing to make sure that they are not misleading,
whatever these words are.

Chairman: Do any of my colleagues have further questions to ask?

Audrey Wise

375. I would just like to get absolutely crystal clear from all four of
you the question of the cost effectiveness of, say, six weeks appropriate
prescribing by GPs of nicotine replacement therapy. If we made such a
recommendation, for example, and obviously I do not know whether the
Committee would be minded to do that or not, could we be shot down in
flames on cost grounds or would we be able to back up such a
recommendation and show its cost effectiveness as well as its
effectiveness?

(Professor Britton) This is a document called Smoking Cessation Guidelines
and Their Cost Effectiveness, which was published a year ago, and the
second part of this section is written by health economists primarily who
looked at the effectiveness of different models of providing smoking
cessation services. We will leave this document for you. As I said
earlier, those costs come out at somewhere between =A3200 and =A3800 per li=
fe
year saved depending on what model one adopts, some are broad reach, some
are restricted access. In terms of health cost effectiveness, smoking
cessation is one of the most cost effective interventions available to us.
I think the median cost effectiveness of the top one hundred medical
interventions shown to prolong life=97and it surprises me sometimes that
there are one hundred medical interventions that prolong life=97is about
=A317,000 per life year saved. Smoking is under =A31,000. That is with six
weeks of nicotine.

376. I appreciate that this is not intended as being an alternative to
public health measures but you all concur?

(Dr O'Neill) Absolutely. Just to reiterate the point that Professor
Britton made earlier on, if someone is using the nicotine replacement
therapy and after a week they are still smoking then there is no benefit
in them continuing. We would not want to give you the impression that we
think everybody should immediately get a six weekly prescription.

377. No, I said "appropriate".

(Professor Britton) I think these are worked out on six weeks so it might
be slightly cheaper than that.

(Sir Alexander Macara) It is not either/or. Helping individuals or
promoting and protecting the public health, it has to be both together.

378. It has been suggested to us as well, and I do not know whether you
agree with this, that nicotine replacement therapy increases the
effectiveness of other forms of health or support or intervention. Is that
so?

(Professor Britton) It doubles the success. Roughly speaking, whatever
else you do is doubled by nicotine, which is why I said earlier that
nicotine=97

379. By nicotine replacement therapy?

(Professor Britton) By nicotine. Which is why I said earlier that nicotine
over the counter without any support at all is probably doubling the
chance of success of somebody who goes into a chemist and thinks "I think
I might try to stop smoking", or "I am going to get something to help me".
In general, the more one puts into smoking cessation, the greater the
return. Bupropion, in so far as it has been studied, seems also to have a
similar incremental effect on top of whatever else you do.

Audrey Wise: So it seems from that that the most cost effective
intervention is, as Dr O'Neill suggested, GPs advising and helping and
discussing plus nicotine replacement.

=A9 Parliamentary copyright 2000 Prepared 2 February 2000

Select Committee on Health Minutes of Evidence

------------------------------------------------------------------------

Examination of witnesses (Questions 380 - 383)  THURSDAY 9 DECEMBER 1999

PROFESSOR JOHN BRITTON, DR JENNY MINDELL, SIR ALEXANDER MACARA and DR BILL
O'NEILL

Dr Brand

380. Primary care team, I think.

(Professor Britton) Not necessarily, no, because there is more to it than
that, but we are talking of small numbers of pounds. In fact specialist
smoking cessation clinics are very cost-effective, but they can only see a
small number of people.

Audrey Wise

381. So smoking cessation clinics plus NRT, GP support plus NRT=97both of
those are definitely spectacularly cost-effective?

(Dr Mindell) And smoking cessation training and support for midwives and
practice nurses and really all healthcare professionals ideally.

Chairman: The GPs are wincing at the moment to that. The PCGs we are
talking about.

Dr Brand: The primary care team, not a PCG, and certainly in my own
experience, I found one of our practice nurses absolutely brilliant at it.
We were funded for smoke stop clinics and then the funding was withdrawn
and people's enthusiasm waned and it was not as good as it was.

Mr Austin

382. Everybody has said not only in this session that smokers become
addicted when they are very young and those who do give up tend to give up
later in life. I would just be interested to know whether you know of any
examples of good practice where young people have been persuaded or
enabled to quit the addiction.

(Dr O'Neill) We can certainly get that evidence for you and send it to you
because there certainly is evidence there from various groups working with
schools and youth groups.

Chairman

383. Do any of my colleagues have any further questions? Do any of the
witnesses wish to add anything to what they have said so far? If not, then
I will thank you, Dr Mindell and gentlemen, for your most helpful
evidence.

(Sir Alexander Macara) And thank you, Chairman, and the Committee for a
most enjoyable as well as, I trust, productive session.

Chairman: Thank you, Sir Alexander.

=A9 Parliamentary copyright 2000 Prepared 2 February 2000