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.

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