THURSDAY 18 NOVEMBER 1999

PROFESSOR LIAM DONALDSON, DR DAWN MILNER, MR TIM BAXTER AND MR PAUL LINCOLN

  40. Or on advertising?
  (Professor Donaldson) No.

  41. There are warnings about tar and health hazards.
  (Professor Donaldson) There is information on nicotine levels but no specific warning on addiction, no.

  42. Do you think that is a mistake?
  (Professor Donaldson) I think it would help a great deal in all sorts of ways to draw attention to the addictive effects of nicotine, yes.

  43. Could you ask the Health Education Authority their views.
  (Mr Lincoln) The position on nicotine is that it has been effectively proven as a highly addictive drug. Obviously nicotine has a therapeutic role as well in terms of nicotine replacement therapies and the like. We feel that any regulation in relation to nicotine with cigarettes should be considered within a common framework, as with therapeutic therapies that use nicotine as well.

  44. Since it is a product which kills half of its users, if the tobacco firms are to stay in business they need to get people addicted and it is in their interests for this to happen preferably at an early stage. Is there some evidence that tobacco companies are quite happy to retain nicotine levels in order to get young people addicted?
  (Professor Donaldson) I think this comes back to an earlier point about what tobacco companies know and have disclosed. One of our recommendations is that there should be a full disclosure by brand of the contents of cigarettes and additives and that there should be full disclosure of scientifically what the tobacco companies know, which is not in the free literature, which would be of great value to public health professionals in developing an evidence base for effective public health action.

  45. Would you also agree that there is a perception amongst the public that the addictive level of nicotine is not particularly high? Where would you rate it in a league table of powerful additives with some other drugs which may be seen as much more dangerous?
  (Mr Lincoln) The consumer research that we have undertaken suggests that people are very confused about nicotine itself. In fact, a survey this year about what consumers know about cigarettes and how they perceive low-tar/light cigarettes showed that 43 per cent of smokers (this was a significant sample) thought that nicotine was also cancer causing. So there is confusion about nicotine and the nature of it, although people do identify that nicotine is an addictive element. 94 per cent of the sample identified that nicotine was an addictive component of cigarettes.

  46. Where would you rate it with other powerfully addictive substances which may be unlawful?
  (Professor Donaldson) I do not know that it has been tested that way, but it is certainly one of the major factors that keeps people smoking, so it is powerfully addictive in that sense and it has some of the characteristics of classical addiction. I do not know that I have the scientific evidence to compare its power of addiction to other compounds.

  47. As is known, the overall number of people smoking has declined since the 1960s although it did rise in 1996. Has the Department made any long-term projections on what they expect to happen to numbers smoking in the future?
  (Mr Baxter) The White Paper set out targets to be achieved. On the assumption that we will achieve those targets we want to reach adult prevalence of 24 per cent from a base of 28 per cent by 2010; nine per cent amongst young children by 2010 from a base of 13 per cent; and 15 per cent of pregnant women from a base of 23 per cent. In effect, by putting those targets in the White Paper the Government is saying "we believe these are achievable and we are going to take steps to achieve them". That is not to say we would not like to over achieve. Would you be interested in global figures because there are some global figures of predictions of prevalence. At the moment there is an estimate of something like 1.1 to 1.2 billion people in the world smoking today, predicted to rise to 1.6 billion or so by 2025. These are very broad brush figures but they give you a sense of what is expected. That is largely because of population growth, expansions into developing countries and so forth.

  48. Can I also ask, what predictions have you made regarding the pressures on the NHS as a result of smoking related incidents in the long term?
  (Mr Baxter) The best answer I can give you at the moment is that if we meet our targets, if we are on track to meet our targets, by about 2005 we might be saving £40 million a year.

  49. From what?
  (Mr Baxter) It is 1.5 billion or so.

  50. Not 1.7?
  (Mr Baxter) There are varying estimates. It could be 1.7. It depends how you measure it.

  51. Right.
  (Mr Baxter) In terms of the tobacco advertising regulations in our regulatory impact assessment, one of the benefits was savings to the NHS in the long term of 20 million to 40 million per annum. I think the 40 million figure for 2005 is probably cautious. You will realise that our modelling depends on the various assumptions but to try to give you some sense of the figures that is the best I can do.

  52. On the question of cost, the cost to the NHS is only a part of the cost, is it not?
  (Mr Baxter) Yes, it is the NHS cost.

  53. There is loss of working, benefits and all the rest of it. Has anybody actually made a calculation of what the cost is to society as a whole, not just the NHS?
  (Mr Baxter) I am personally not aware of that.
  (Mr Lincoln) The total cost I do not know, but we have just commissioned and will shortly be publishing a paper about the impact of smoking cessation which even in the short term is dramatic in terms of admission to hospitals and the likelihood of AMI, stroke, renal failure, and the like. We are just about to publish a paper fairly soon which we have commissioned through the London School of Hygiene and Tropical Medicine which is looking at a model of economic consequences of smoking cessation both in the short and in the longer term. If it would be helpful to the Committee we could furnish you with a pre-publication draft of that in further evidence.

  54. We would be very grateful.
  (Mr Lincoln) For AMI and stroke it is reckoned to be 500 million by 2010.

  Audrey Wise: That is the health costs. John's question was about the other costs.

  Chairman: The wider social costs.

  Mr Austin: The wider economic and social costs.

  55. Including loss of working time and, of course, there is then loss of taxation and all of that. It is more of a social audit. Has anything like that been done?
  (Mr Lincoln) My understanding is that it is very hard to get that information and to the best of my knowledge it has not been. There is not a complete analysis, there are partial analyses but they have not been synthesised comprehensively.

  Chairman: Anything you have got would be helpful to the Committee.

  56. Could I suggest that it is quite a hole. Admittedly this sort of thing is difficult but such projections are made about the cost of back pain, for instance, regularly expressed in terms of working time lost and costs to industry. If it can be done for back pain, even if that is incomplete, I cannot see why it cannot be done for these sorts of things as well.
  (Mr Lincoln) That is what we have attempted to do based on meeting the Government targets and also on the basis of known evidence of effectiveness and what might actually occur given the level of investment the Government is making in terms of smoking cessation and prevention.

  Dr Stoate: Could I just make a comment really. It is a major gap in our knowledge about the effects of smoking. The argument always given by smokers and smoking groups is that the amount of money they pay to the Exchequer in taxation far outweighs anything the Health Service spends on repairing the damage caused by smoking, which of course is a totally fallacious argument. It is absolutely essential if we are going to have a national debate that we understand the full social costs. I am quite worried that the Governments over the years have not collected information about the social costs. It is not actually that difficult to measure the costs of benefits, to measure the costs of pensions, to measure the costs of days lost to industry per year through smoking related illness. That cannot be difficult to collect. Surely there must be statisticians out there in social policy units or universities or somewhere who have done this work? I am really rather concerned that has not been collated and not made available to us because I believe it is an essential part of the inquiry.

  57. Just leading on from this area of cost, can I just get a categorical reconfirmation presumably of Government policy and that is there is no policy within the health service as part of a cost saving exercise for individuals suffering from smoking related illnesses, because they are smokers, being rationed or refused treatment?
  (Professor Donaldson) Irrespective of cost cutting considerations, in my view that would not be a properly ethical policy. It may sometimes be necessary in a planned procedure to ask a patient to stop smoking in the run-up to it in order to reduce their risk of complications from the operation or the anaesthetic, but it would not be a proper basis for deciding clinical need, it is irrespective of somebody's life style.

  58. No doubt you will remember three years ago or so when this came to light and it was stamped on and that is still the case.
  (Professor Donaldson) Yes.

  59. Can I ask what internal resources, both in terms of staffing and finance, does the Department have to analyse and understand the technical composition of cigarettes?
  (Dr Milner) We have a scientific adviser, Professor Frank Fairweather, who is a consultant to our team who works one day a week. We have another scientific adviser who works with us two days a week and I work full-time in the team. In addition, we have access to a technical advisory group via the Scientific Committee on Tobacco and Health and papers are prepared. If I can explain to you, when the industry wishes to use a new additive they will come to us and we will ask for certain information about that additive and draw up an assessment and prepare a paper for the technical advisory group to assess whether or not we are able to give approval to that additive.