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Aim:
To assist smokers to quit and stay quit
How: To provide cigarette smokers with
alternatives to inhaling toxic smoke to get their nicotine, and instead
use pure smokeless nicotine, so smokers can quit smoking first, then
decide whether to quit nicotine at the same time or later, or not at all.
NRT-related policies
required to assist smokers to quit and stay quit
·
Widen the approved uses of
pure nicotine through the smoking cessation guidelines.
·
Continue the government subsidy
of NRT (nicotine replacement therapy) patches and gum.
Safety
·
Over 3000 ex-smokers used
nicotine gum for 5 years. No increase in deaths or hospitalizations was
found1, compared with those not using gum, whether or not
the gum chewers were still smokers.
Rationale
·
Pure nicotine replaces
nicotine otherwise obtained from smoking.
Revised UK Guidelines for the use of NRT (note from ASH UK on Globalink
29 Dec 05)
- All forms of NRT can be used by patients with
cardiovascular disease.
- All forms of NRT can be used by smokers aged 12 to 17
years.
- NRT can be used by pregnant smokers, if it is needed to
stop the smoking.
- More than one form of NRT can now be used concurrently.
- NRT can now be prescribed for up to 9 months if patients
show evidence of a continued need for NRT beyond the initial 8 to
12 week treatment phase.
- NRT can now be used while still smoking, with a view to
reducing the amount smoked as a prelude to quitting.
Review of NRT in the USA
The seduction of harm
reduction. Proceedings of the Sept. 2004 Summit. Sacromento CA. Dept
of Health Services 2005. http://www.dhs.ca.gov/tobacco/documents/pubs/HarmReductProceedCompleteBooklet.pdf 8 MB, at session 4.
Proposed
nicotine replacement policies for New Zealand
(1) Widen the approved uses
of pure nicotine through the smoking cessation guidelines
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Current policy on the uses of nicotine
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Proposed policy
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Short term smoking cessation aid. This includes almost
all current use of NRT. Medicinal nicotine (nicotine replacement
therapy products or NRT) is licensed under the Medicines Act to treat
withdrawal symptoms.
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Continue the
subsidy, and expand to cover a wider range of providers and of NRT
products. For method of finance see (2) below.
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Instead of a cigarette. (example: to
cope with smoking restrictions)
NRT
is sold over the counter, but officially long term use is not
encouraged or subsidised.
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Encourage
addicted smokers to smoke fewer cigarettes, by using nicotine instead
of a cigarette.
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Long term relapse prevention. Not subsidized
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Subsidise long-term NRT to
prevent relapse to smoking.3
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1
Murray
RP, Bailey WC, Daniels K. et al. Safety of nicotine polacrilex
gum used by 3,094 participants in the Lung Health Study. LHS Research
Group. Chest 1996; 102: 438-45.
2.
Blakely T Laugesen M. Symons R et al. New Zealand cigarettes have a high nicotine content. NZ Public Hlth Rep.1997; 4: 33-4
3 Medioni J, Berlin I, Mallet A. Increased
risk of relapse after stopping nicotine replacement therapies: a
mathematical modeling approach. Addiction 2005; 100: 247-54.
The NZ Ministry of Health is
commissioning a review in 2006.
(2) Tax
each tobacco product according to the risk of using it. Abandon the current flat tax per gram of
tobacco across all classes of tobacco.
·
Double the tax on hand rolled RYO cigarettes www.endsmoking.org.nz/RYOtax.htm
·
Maintain
the tax rate on manufactured cigarettes and cigars www.endsmoking.org.nz/taxandrisk.htm
·
Decrease
the tax on snuff by 90%.
(3) Tax only the smoking tobaccos for
nicotine content.
·
Nicotine content tax. Develop a policy to tax only smoking tobacco products based
on nicotine content. This encourages cigarette manufacturers to reduce
excess smoke nicotine.
· Consider
using nicotine tax to cross-subsidise all types of NRT products (not just gum
and patches).
(4) Extend the
subsidy on NRT to cover
NRT use for long term relapse prevention.
(5) Subsidise pure nicotine products: support Pharmac to continue this policy.
Since 2000, Government, through district health boards and Pharmac, their drug buying agency, funds a
substantial subsidy on nicotine patches and gum for those smokers
assisted by the Quit Campaign.
(6) Support research
to develop and test fast-acting nicotine products
Medicinal nicotine is expensive,
is designed for safety, for short term use, and to not cause addiction.
There is a need for popularized oral nicotine products which smokers may
actually want to use instead of cigarettes. Smokeless tobacco proves
that nicotine can be absorbed within five to ten minutes from the
mouth. The research question is whether nicotine products can be
designed to be a popular substitute for smoking, or whether smokeless
tobacco is needed to fulfil that role, as in Sweden.
(7) Encourage the sale of non medicinal nicotine to increase
price competition.
Non medicinal nicotine products are
virtually missing from the NZ market. The high markups on medicinal
nicotine products discourage smokers from using nicotine instead of
cigarettes, on a temporary or permanent basis.
Background:
Current legislative framework for nicotine-containing products
1
Cigarette nicotine as in smoking tobacco can be sold by
any retailer, but not to under-18s, under the Smoke-free Environments
Act. (“dirty” nicotine because it is mixed up with
poisonous gases)
2
Nonsmoking tobacco nicotine as in oral tobacco is banned
from sale or promotion, though import for private use is permitted.
This is controlled by the Smoke-free Environments Act.
3
Medicinal nicotine products are controlled by the
Medicines Act. Some NRT can be sold in supermarkets. Most are sold
through pharmacies or dispensed through the subsidized scheme. Spray
requires a prescription.
4 Non-medicinal nicotine
can be freely imported or sold. Nicotine can be sold for non-medicinal
purposes in NZ, (general sale) as long as no claim is made that cures
people of withdrawal symptoms etc. It is however permissible to claim
it can be used as a substitute for cigarette smoking.
The cost of providing ‘clean’
nicotine as an alternative to the nicotine in (toxic) smoke
·
NRT costs less than a packet
of cigarettes – but dose for dose RYO cigarettes supply cheaper
nicotine.
·
Dose for dose of nicotine, only 15mg
patches and 4mg gum are cheaper than manufactured cigarettes.
Table 1. NRT costs less
than a packet of cigarettes- so what is the problem?
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Nicotine source
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Pieces/
pack
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RRP
$
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$/cig. $/Piece
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Pieces used per day*
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$ Cost/
Day
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Cigarettes Holiday 20
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20
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9.25
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0.46
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18
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8.42
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Cigarettes RYO in 30 g tobacco
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83
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17.95
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0.20
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18
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3.92
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GUM 2mg
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|
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Gum Classic 2mg 15
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15
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7.45
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0.50
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9
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4.47
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Gum Mint 2mg 15
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15
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7.45
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0.50
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9
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4.47
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Gum Classic 2mg 30
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30
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12.95
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0.43
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9
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3.89
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Gum Mint 2mg 30
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30
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12.95
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0.43
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9
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3.89
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GUM 4mg
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|
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Gum Classic 4mg 15
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15
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8.95
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0.60
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9
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5.37
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Gum Mint 4mg 15
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15
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8.95
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0.60
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9
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5.37
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Gum Classic 4mg 30
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30
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15.95
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0.53
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9
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4.79
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Gum Mint 4mg 30
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30
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15.95
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0.53
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9
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4.79
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TABLET
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Sublingual tab. 30
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30
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19.70
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0.67
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9
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6.03
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PATCH
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Patch 15mg 7
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7
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24.95
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3.56
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1
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3.56
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Patch 10mg 7
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7
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22.95
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3.28
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1
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3.28
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Patch 5mg 7
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7
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19.95
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2.85
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1
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2.85
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1.
Fraser T, McRobbie H et al. Evaluation of Smokestop
an internet based smoking cessation programme. Auckland, 2006. For cigarette data see Table 1, at www.smokeless.org.nz/ryotax.htm
2.
Average
pieces of NRT per day: D.Barlow, NHF. Sept 2005.
Dose for dose of nicotine,
·
The only NRT cheaper at retail than manufactured
cigarettes is 4 mg gum, and the 15 mg patch:
·
All NRT is more expensive than RYO
cigarettes.
Table 2. Nicotine absorbed and cost per milligram absorbed
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Nicotine product
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Nicotine content
mg
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Nicotine absorbed per dose2
Mg
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Cost per piece
$
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Cost per mg nicotine
$
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Cigarettes Holiday 20
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131
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1.4
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0.463
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0.33
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Cigarettes RYO 18 x 0.36g4
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6.5
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1.4
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0.20
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0.14
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GUM 2mg
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Gum Classic 2mg 15
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2
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1
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0.50
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0.50
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Gum Mint 2mg 15
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2
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1
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0.50
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0.50
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Gum Classic 2mg 30
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2
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1
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0.43
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0.43
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Gum Mint 2mg 30
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2
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1
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0.43
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0.43
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GUM 4mg
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Gum Classic 4mg 15
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4
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2
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0.60
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0.30
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Gum Mint 4mg 15
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4
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2
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0.60
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0.30
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Gum Classic 4mg 30
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4
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2
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0.53
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0.27
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Gum Mint 4mg 30
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4
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2
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0.53
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0.27
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TABLET
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Sublingual tab. 305
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2
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1
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0.67
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0.67
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PATCH
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Patch 15mg 7
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15
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15
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3.56
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0.24
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Patch 10mg 7
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10
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10
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3.28
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0.33
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Patch 5mg 7
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5
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5
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2.85
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0.57
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1. Blakely T Laugesen M. Symons R et al. New Zealand cigarettes have a high nicotine content. NZ Public Hlth Rep.1997; 4: 33-4.
2. Fagerstrom K. The nicotine market:
An attempt to estimate the nicotine intake from various sources and the
total nicotine consumption in some countries. Nicotine Tob Res
2005; 7: 1-8.
3.
Health New Zealand. Analysis of
Manufacturers Returns 2004. www.ndp.govt.nz
Table F.
4. Taxation of RYO
cigarettes in line with the risk. Table 1. www.endsmoking.org.nz/ryotax.htm
RYO cigarettes averaged 0.36 gm tobacco, and 18 smoked daily. Because
the addiction rate was no less smoking RYO cigarettes, it is assumed
that the nicotine extracted was 1.4 mg as for manufactured cigarettes.
5. Available from pharmacy
only.
Table 3 shows that current practice or
recommendations mean that many smokers quitting by using NRT will be nicotine
deprived, and so vulnerable to resuming smoking.
For example, one 15 mg patch only replaces
half the nicotine previously obtained from smoke.
As Table 3, shows, to fully replace cigarette
smoke nicotine, the core products NRT 4mg gum, and NRT 15 mg patch do cost less
than manufactured cigarettes, but for RYO smokers, cigarettes are
cheaper.
The cost of fully
replacing the smoke nicotine
Table 3. Since NRT only
provides partial replacement of cigarette smoke nicotine, what is the
cost of full replacement?
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Nicotine source
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Nicotine absorbed daily, based on average number of pieces used
mg*
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Previous column as %
of daily cigarette nicotine
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Cost per piece*
$
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Amount of Nicotine required for full replacement
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Daily cost of full replacement of cigarette smoke nicotine
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Cigarettes Holiday 20
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28
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100
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0.46
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1 packet
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9.25
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RYO cigarettes 18
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25
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100
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0.20
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1
packet
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3.92
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GUM 2mg
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Gum Classic 2mg 15
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9
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32
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0.50
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2 packets
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14.90
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Gum Mint 2mg 15
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9
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32
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0.50
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2 packets
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14.90
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Gum Classic 2mg 30
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9
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32
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0.43
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1 packet
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12.95
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Gum Mint 2mg 30
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9
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32
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0.43
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1 packet
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12.95
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GUM 4mg
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Gum Classic 4mg 15
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18
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64
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0.60
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1 packet
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8.95
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Gum Mint 4mg 15
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18
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64
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0.60
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1 packet
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8.95
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Gum Classic 4mg 30
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18
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64
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0.53
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½ packet
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8.00
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Gum Mint 4mg 30
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18
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64
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0.53
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½ packet
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8.00
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TABLET
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Sublingual tab. 30 #
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9
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32
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0.67
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1 packet
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19.70
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PATCH
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Patch 15mg 7**
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15
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54
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3.56
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2 patches
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7.10
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Patch 10mg 7**
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10
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36
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3.28
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3 patches
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10.95
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Patch 5mg 7**
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5
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18
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2.85
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6 patches
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17.10
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*From Tables 1 and/or 2
above.
# Pharmacy only.
** These weaker patches are
actually used to wean people off the 15 mg patches.
The quantity of NRT
required for full nicotine replacement may be greater than shown in
Table 3.
·The estimate of 1.4
mg absorbed, is an average only; smokers vary greatly in the amount of
nicotine they need to inhale per cigarette.
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