Smoking has been so much part of our culture for so long that it is hard to imagine a world without it. Yet that is exactly what the Royal College of Physicians (RCP) called for last week. The RCP suggested that, with a concerted effort, smoking could be eliminated within 20 years.
To achieve this, two things would have to happen, the college said. First, curbs on smoking would have to be strengthened, principally by ramping up taxes on tobacco. But second, and more important, access to nicotine in other, safer, forms has to be greatly increased.
This latter demand chimes with developments under way in the tobacco industry. This week, the Marlboro cigarette empire Altria bought the USA's biggest maker of chewing tobacco, UST, for $10.4bn (£5.8bn). The deal confirms the tobacco industry's interest in diversifying out of cigarettes into "smokeless" products. UST makes Skoal – tea bag-like pouches of tobacco that are held between the cheek and gum, allowing nicotine to be absorbed.
British American Tobacco is also investing heavily in the search for safer ways to deliver nicotine. BAT paid £2bn to take control of the Swedish company ST, which makes Snus – also pouches of tobacco for sucking.
Evidence suggests that sucking a pouch of tobacco is 90 per cent less harmful than inhaling cigarette smoke. But the products are banned in the EU on the grounds that they are, er, carcinogenic, and that to replace one carcinogen with another, albeit one less lethal, is unwise.
Meanwhile, investigations are under way into alternative ways of delivering nicotine that will satisfy the most hardened of addicts. As more smokers give up, those who puff on are the ones who require most support to quit. Nicotine gum and patches won't cut it; these are addicts who need the "hit" that only a lungful of smoke supplies.
Nicotine is the closest we are likely to get to the perfect drug. Its effects are diverse; it stimulates, calms and enhances feelings of pleasure, but has few side effects. Its great advantage over other drugs is that its effects are mild. It is pleasurable only within a narrow range of concentrations in the blood. That is what makes it safe.
Only the instrument of its delivery – the cigarette – is lethal. A device that delivers nicotine quickly, efficiently and safely could earn a fortune. But regulations on the sale of medicinal nicotine are so tight that they keep prices high – seven days' worth of nicotine patches costs £17 – and the development of innovative products low.
Professor John Britton, consultant respiratory physician and chief author of the RCP report, said: "The ideal product would be a nicotine inhaler like an asthma inhaler, that delivered a hit of nicotine as close as possible to the experience of smoking a cigarette.
"But the companies [makers of nicotine gum and patches] don't want to do it and the regulatory restrictions make it difficult to get it on to the market. There is no competition. That is why we need a Nicotine Regulatory Authority."
The anomaly in the existing law is glaring. Tobacco companies are permitted to sell nicotine to the public in the form of (lethal) cigarettes, yet it is illegal to sell alternative nicotine products without a licence.
Nicotine patches and chewing gums available on prescription and, now, sold over the counter are strictly regulated medicinal products designed for short-term use by people trying to quit. They do not deliver the hit required to satisfy hardened smokers.
Tobacco companies have experimented with smokeless cigarettes, nicotine sprays and other devices, without success. Smokers say the products have been unpleasant to taste, difficult to use and hard to smoke.
What is needed is a medicinal nicotine product designed not as a short-term crutch to support the quitter, but for long-term use as part of a "harm reduction" approach. This idea is backed by the Royal College of Physicians and by Ash, the antismoking charity, but it causes disquiet among some public health experts who blanch at the prospect of condoning nicotine dependency.
Yet an effective medicinal product would be a better option than chewing tobacco. The evidence suggests that nicotine is, if anything, less harmful than caffeine – if it carries less risk than a cup of coffee, where's the problem in making it freely available in a more attractive form? And many in the health field are suspicious of the tobacco industry, believing that the promotion of sucking pouches is another way to keep us hooked on tobacco.
There are signs that the Government may be willing to listen. Close readers of its cancer reform strategy, published last year, noted that the Department of Health said it would consult on measures "to reduce the significant harm to health caused by smoking for those who are addicted to nicotine and not able to quit altogether".
Britton, who is the head of the Department of Public Health at the University of Nottingham, points to the lives such a strategy could save. Of the 10 million current smokers in Britain, half will die prematurely if they do not quit.
He says: "If these people can be encouraged to use a safer product instead, the impact on public health would be huge. If we end up with a society in which a lot of people use a safe nicotine product every day, so what?"Reuse content