Wednesday 17 August 2011

The medicalisation of pleasure

Some interesting news from Switzerland, where nicotine addiction is to be classified as a disease.

Following a Federal Court ruling, the Federal Health Office has concluded that nicotine addiction can be considered an illness. Basic compulsory insurance, which currently does not reimburse any anti-tobacco medication, will have to pay up.

On August 4 the Federal Court underlined that alcohol and heroin addiction could be considered an illness and that “under certain conditions” so could dependence on nicotine. In this case, insurance companies would have to reimburse medicines to treat smoking addiction.

This is intriguing for a number of reasons. Anti-smoking extremists generally oppose the idea that smoking/nicotine addiction is a disease/disability, because the diseased and the disabled have rights. Nicotine addiction is specifically excluded from disability laws in several countries to prevent smokers complaining about discrimination. Anti-smoking campaigners have to tread a fine line between saying that cigarettes are more addictive than heroin, on the one hand, and insisting that smoking is a matter of free choice that can be stopped at any time.

The pharmaceutical industry is not so bothered about maintaining this balancing act. Their lobbyists would like to entirely medicalise the issue in order to position their own products as the 'cure'. And it is they who have been the main drivers of the Swiss decision, as the headline of this story makes clear.

Tobacco ruling has a financial side

Indeed it does. Step forward, Pfizer...

The court partially agreed with drug maker Pfizer which wanted its Champix (or Chantrix) medication included in the list of medicines reimbursed by basic insurance.

'Reimbursement' has always been Big Pharma's aim. It is nice for them to be able to sell drugs like Champix or Nicorette to those who want to quit, but it is even nicer if the government (or insurance companies) buys their stock en masse and dishes them out to smokers as a matter of course.

This intention has been clear since 1999, when Glaxo, Novartis and Pharmacia became big-spending partners with the World Health Organisation to achieve a tobacco-free (note, not nicotine-free) world. In that year, Greg Deener, Glaxo's Director of Global Commercial Strategy, gave a speech which explained exactly what they wanted in return.

We want to support and be partners in tobacco control in a number of areas. We could use help in the area of reimbursement. Zyban was first launched in the US, but as yet there is minimal reimbursement for Zyban in the US. In the US, 42% of people on Medicaid smoke. Federally, Medicaid does not require reimbursement for smoking cessation because it is a lifestyle decision, in the same category as hair replacement... Reimbursement will increase quit attempts, make physicians more proactive.

Do you think he mentioned reimbursement enough? For the pharmaceutical industry to maximise its profits, the government must buy up their NRT products as if they were antibiotics, but for that to happen—as Deneer made clear—smoking cannot be seen as a "lifestyle decision", but as a disease.

This is a very iffy proposition, because smoking is not a disease, rather it is a risk factor for disease, as the insurance companies have pointed out.

For their part, health insurance companies have denounced the “negative message.”

“We only cover risk of illness and not prevention, which is not a risk. Prevention is down to individual responsibility and can’t be carried by everyone. This would be putting all types of behaviour under state control,” explained Yves Seydoux, spokesman for Groupe Mutuel.

But others have equated nicotine addiction with alcoholism, and there is a case to be made that if other addictions are considered diseases, then so should nicotine addiction.

Jacques de Haller, president of the Swiss Medical Association, does not quite agree. “From a medical point of view the two pathologies are different, but both are a dependency.”

“A smoker is addicted to tobacco which makes him lose his free will and can considerably shorten his life,” he said. In addition, there is “the real problem of passive tobacco addiction”.

I have literally no idea what "passive tobacco addiction" is supposed to mean. I wonder if even he knows. It seems that you can stick the word "passive" into any sentence and get people to nod their heads in solemn agreement.

Leaving that aside, it seems to me that the real problem here is that if you classify nicotine addiction as a disease, then industries that sell nicotine products are part of the problem, and that includes Big Pharma. As ineffective as they are, NRT products have a role as one of the options for people who want to quit smoking for the sake of their health. But if the problem is redefined as being nicotine addiction itself, they are clearly not a solution. It could even be argued that since NRT is much safer than smoked tobacco, the pharmaceutical products encourage people to stay addicted for longer. Put simply, nicotine products are not a cure for nicotine addiction.

But what else can Big Pharma do? They can't claim that their NRT products cure lung cancer and they can't claim they prevent smoking. If they are to be viewed as medicines, it can only be as a 'cure' to smoking, but smoking is a lifestyle choice and can only be viewed as an addiction if all nicotine use is classified as an addiction and, therefore, a disease.

It doesn't make a whole lot of sense, but that doesn't seem to have stopped the Swiss. This is a major achievement for Pfizer as it sets the scene for the full medicalisation of nicotine. And medicalisation leads to prohibition.

At the start of the last century, a man could go into a shop and buy virtually any stimulant, narcotic, drink or tobacco product he wished, including opium, morphine and cocaine. By the start of the twenty-first century, only a handful of drugs remained publicly available—specifically: caffeine, alcohol and nicotine, of which only alcohol is an intoxicant. The rest had undergone prohibition, but what we call prohibition was really medicalisation. The drugs never disappeared, nor were they intended to disappear. Instead, a system which allowed ordinary people to use mood-altering substances as they saw fit was replaced by a system in which the power to distribute drugs was confined to the pharmaceutical industry and the medical establishment. Even under alcohol Prohibition in the 1920s, doctors were permitted to sell booze.

This enhanced the power and prestige of the doctors, and increased the profits of the drug companies. That is not to say that prohibition was their doing—on the contrary, the pharmaceutical interests initially opposed drug prohibition—but if you ask cui bono?, that is your answer. The sweeping prohibitions of the last century have largely been the work of moral entrepreneurs and zealous reformers, but the effect has been to medicalise a whole range of pleasure-giving substances, of which only a handful remain. In the process, a whole new range of 'diseases', 'syndromes' and 'addictions' has been invented which allows pharmaceuticals to be prescribed to an ever-greater number of people.

If this trend continues, it would be natural for nicotine and alcohol to go the same way eventually. As David Nutt and others have pointed out, there is no scientific reason for these drugs to be legally available when other drugs are classified substances. Alcohol is under no threat of imminent prohibition as long as the American fiasco remains in the popular memory, but David Nutt is personally working on developing a synthetic alcohol substitute and the government's guidelines on 'safe drinking levels' are so low as to be essentially medicinal.

The campaign against tobacco is far more advanced and, again, it has been pushed along by moral entrepreneurs to the benefit of the pharmaceutical industry. More recently, as events in Switzerland show, the pharmaceutical industry has taken a more active role. The long-term goal might be to have a similar nicotine market to that which already exists with drugs, ie. people acquire the habit on the black market and seek 'treatment' (which is actually maintenance of addiction) from doctors who prescribe pharmaceutical substitutes.

Tobacco and alcohol survived the prohibitionist wave of the twentieth century by no more than historical accident. There is no reason to be expect them to be around forever.


Large Melot Please said...

This is what the taxpayer spunks on Zyban and Varenicline according to the NHS.

"In 2010/11 total expenditure on NHS Stop Smoking Services in England (excluding Nicotine Replacement Therapy (NRT), Bupropion (Zyban) and Varenicline (Champix) prescriptions) was £84.3 million."

Readers may also be interested in my speech I gave at the BMJ Quality and Safety in Healthcare Forum in April of this year. "The session will feature a panel of four expert speakers to debate the extent to which tobacco use should be a medically recognised condition as opposed to a lifestyle choice, and the level to which the state should intervene to restrict and redress tobacco use amongst its citizens."

I am pleased we convinced many of the audience who were smoking cessation industry representatives that it is a habit.

Here is a copy of my speech some of it is in note form.

Anonymous said...

I have just read 'large Merlot's figures as reported by the BBC. They also stated that this £83m was to treat just 788,000 people - most of whom failed to quit. That must work out to about £10,000 per person ???. It would be nice if they could just give me the £10k and leave me alone.

Dick Puddlecote said...

When the pharma companies managed to get NRT approved for prescription, I reckon they held some wild celebratory parties.

Over half a mill from Worcs this year and the taxpayer pays the lot. Forever.

Anonymous said...

Sorry, my comment at 19.08. Think I got my maths wrong. £1000. per person - still alot.

Christopher Snowdon said...

Upon reflection, it occurs to me that Champix isn't a nicotine replacement drug, so it could be said to treat the 'disease' of nicotine addiction. Telling, perhaps, that it was Pfizer and not the other pharma companies involved in this lobbying. (I wonder how the makers of NRT feel about it?)

On the face of it, it's risky for them to place so much emphasis on Champix, which might get banned, but opiate addiction is treated with opiates without anyone getting too hung up about it so maybe it won't matter.

Ivan D said...

I find the relationship between the WHO and pharmaceutical companies disturbing.

In recent years the WHO has become increasingly dependent on extra budgetary funding effectively making it for sale to the highest bidder. It has also become increasingly proactive as a lobbying organisation, politicised and focused on lifestyle choices in Western societies. All of which have distanced it from its original laudable objectives.

This process seems to have coincided with the leadership of Gro Harlem Brundtland who took the reins back in 1998. This is hardly surprising as she is a left wing autocrat with a medical degree, a Masters in public health from an American school and a burning desire to eliminate tobacco completely. She is also a very successful politician. She left the WHO back in 2003 but her anti-tobacco legacy lives on.

I wonder how much the WHO costs UK tax payers each year. Most people working in research tend to think of it as corrupt and bureaucratic but WHO grants are much sought after as a licence to print money.

George Speller said...

DP - what's amazing is how quickly "NRT" moved from being prescription only to being openly available on supermarket shelves. Incidentally as it's not a tobacco product can minors buy it?

nisakiman said...

"passive tobacco addiction"? "passive tobacco addiction"?


This is all starting to border on the surreal.

What is it with these people that they feel they have to intervene in my (and millions of others') life? It just goes on and on, becoming ever more hyperbolic.

I sometimes wonder how much all this has cost over the last few decades (all the global conferences, all the research into smoking and SHS) and how many lives it has destroyed (as a result of the global smoking bans, businesses destroyed, people thrown out of work), and if the zealots really think it's all been worth it.

It all seems so pointless.

Anonymous said...


Things could have been worse.

Nicotine gum and patches to be sold in pubs and clubs
Sunday, 8 November 1998

"NICOTINE GUM is to be sold in pubs, clubs and corner shops alongside cigarettes, following a landmark ruling by the Government's medicines regulator.

The Department of Health's medicines watchdog has lifted a ban on selling Nicorette chewing gum outside chemists to help people give up smoking.

The move, to be announced this month, is the first step in a major review of government policy on smoking and health.

It comes on the eve of a White Paper in which ministers will announce plans to hand out free nicotine gum and patches to those on low incomes."

The ruling on nicotine gum by the Medicines Control Agency opens the route for nicotine patches and stronger nicotine-based products to be sold by ordinary shopkeepers, publicans and restaurateurs. "It's absurd that you can buy cigarettes anywhere and at any time of day or night but with pharmaceutical products it's much more difficult to get access to them," said Martin Jarvis, Principal Scientist at the Imperial Cancer Research Fund. "We know that nicotine replacement helps people to quit and making it more widely available is a good thing."

It decided to lift the ban on selling 2mg nicotine gum after an application by the manufacturer of Nicorette, Pharmacia & UpJohn."

But according to a market survey for ASH in 2005, in 2002, even for free only 2% took up the offer.


Unknown said...

Disease state- why not. The science of addictive diseases often obscures the science behind the disease. We at this time target nicotine as the culprit and tobacco as the vehicle. In the world of research nicotine may not be as addictive as it is touted. Tobacco contains multiple alkaloids and effects multiple brain receptors. It is also an effective inhibitor of MAO- monoamine oxidase, an enzyme that is throughout the brain and body. There are good studies that relate other alkaloids in tobacco (anabasine and other compounds) to MAO inhibition and cravings. Is this why NRT replacement is so miserably failing those who try to quit smoking? There is much to discover, and understand. Smoking kills, as the Lancet pointed out in several editorials- why is tobacco (Big T) and NRT (Big Pharma) reeling in the money while prolonging this "disease" when grassroots methods like vaping and easily verifiable data on SNUS are under attack? Money talks, whether it be profits to Big T or Big Pharma or taxes to the government- Smoking kills but not well enough to allow the real winners Government, Big T and Big Pharma to allow alternative methods to be attainable.

Anon1 said...

"Medicalization of pleasure"

It is not just the medicalization of “pleasure”. It is the medicalization of everyday life, from anxiety to depression; the bulk of human experience reduced to chemical “dependence” or chemical “imbalance”, requiring – you guessed it – pharmaceutical “remediation” or medical “therapy”. The art and detail of living, of relating, issues of integrity and honorable conduct, are all gone, vanquished, in this sterile, destitute, reductionist framework.

Gigantic Pharma is just one critical part of a greater problem – the medical industrial complex (MIC). Health has again been reduced to only a biological phenomenon. Terrorizing the public, a constant play on the primal fear of disease and death - which is not considered a health issue in a biological framework - is highly lucrative. Part of the MIC is ideologically-driven (eugenics), conducting itself as a dictator of lifestyle right to the micro-management level; the concerns are obviously physicalist. Partnering with this ideological aspect that manufactures problems that do not exist and disregards problems that do exist, are the financial interests, e.g., Gigantic Pharma. It is a very sick, dangerous system.

The original Rockefeller, a paragon of self-interest and avarice, would be salivating, drooling uncontrollably, at the social power that the medical establishment has fraudulently acquired: It’s what he would have had in mind all those years ago - social control/engineering and profound money-making potential. Rockefeller would be pleased indeed.

Anonymous said...

A fascinating and informative post as usual. As I cannot add very much to the erudite comments above I thought I would contribute a little insight into the personal lunacy of a leader in the public health movement.