Smoking

HL Deb 17 May 2004 vol 661 cc597-614

7.53 p.m.

Baroness Rendell of Babergh rose to ask Her Majesty's Government what is their view of the therapies available to help people to stop smoking.

The noble Baroness said: My Lords, everyone in the United Kingdom is aware by now that smokers should give up their habit. Smoking, restricting smoking, banning smoking and the effects that it has, both active and passive, on the health of the nation are in the news almost every day. Certainly, a week never goes by without the announcement of some new restriction on smoking—or the disastrous result of it on our hearts, lungs and circulatory systems—appearing in the media. Today, for instance, sees the presentation of the findings on passive smoking at a conference organised by the Royal College of Physicians. Great stress is placed on the need for smokers to give up and many therapies have been developed advising on how to do so. Smoking is said by some to be more controlling and enslaving than a heroin dependency.

It is 27 years since I stopped smoking, but I still remember the horror and the very real anguish and longing I suffered after I gave up those 30 or so cigarettes a day that I had been smoking. I do not mean to go into case histories this evening, least of all my own. Apart from trying cigarettes stuffed with dried lettuce leaves, which would in any case have solved only part of the problem, I found no aid available. Now I see herbal cigarettes are back again as a suggested remedy to help people to conquer their craving. Do Her Majesty's Government realise how difficult it is to stop? When they advise people to stop smoking, there are entering a quality of life area, where by giving up his or her addiction the smoker may see the whole purpose, routine and programme of life change, a support one always relied on in times of stress or crisis banished, and a supreme pleasure snatched away.

What is being done to ease the passage of addicts—I see nothing wrong in using this word, I know that I was an addict—from the dependency that has them in its grip to a final freedom from cigarettes? According to Cancer Research UK, simple interventions such as the advice of a doctor, nurse, pharmacist, dentist, or other health professional, are powerful motivators to stop smoking, and encouragement is given to all health professionals to ask patients at least once a year about their smoking and offer advice about giving up.

Apart from the herbal cigarettes that I have mentioned, there are systems called Smoke Rx and 7-Day Smokeaway, each of which provides a week's supply of natural supplements and aromatherapy. The promoters of the systems recommend focusing the mind on kicking the habit and the repetition of the mantra, "Let's get healthy". Probably the oldest aids are those which come into the category of nicotine replacement therapy; nicotine gum and nicotine patches. The gum is chewed until the taste becomes peppery, and while it rests in the mouth the nicotine is absorbed through the cheek into the bloodstream. This process is to be repeated once the taste of the gum fades for 30 minutes. Ten or 12 pieces of gum a day for one to three months is recommended.

Nicotine from a patch placed directly onto the skin is absorbed into the bloodstream throughout the day. The 16-hour patch is used during the day and thrown away at night, while the 24-hour patch is worn all the time and replaced during the day. It is said that United Kingdom smokers reach for that first-thing-in-the-morning cigarette earlier than everywhere else in Europe, and the manufacturers of the patch claim that this type is particularly suited to heavy smokers who crave a cigarette on first waking up in the morning. Experts believe that the need for an early cigarette could be one reason why two out of three attempts to quit the habit by smokers in this country fail within a week. Patches have been available on the NHS, I believe, for the past three years.

The first kind of nicotine replacement therapy claimed to deal with both elements of smoking addiction—the physical and the psychological—is the inhaler, called the "inhalator". A cartridge is inserted into a tube about the size of a small cigarette holder. Sucking on the end of the inhalator pulls nicotine vapour through the cartridge, which is then absorbed through the mouth and throat into the bloodstream. Each cartridge lasts about 20 minutes and between six and twelve a day may be used, each providing a low dose of nicotine over a long period. This system seems to satisfy the craving for a nicotine rush. The drug Bupropion, trade name Zyban, apparently helps take away cravings and helps with withdrawal. The inhalator cartridges cost about two-thirds of what cigarettes cost and can be bought over-the-counter from pharmacists and supermarkets, but both Zyban and nicotine replacement therapy are available on National Health Service prescription. According to Cancer Research UK, these medications approximately double a smoker's chances of stopping. Can my noble friend tell the House what side effects, if any, Zyban has?

Breath carbon monoxide monitors have apparently been in use for 20 years. The help that they give seems to consist in giving the smoker visible proof of his damaging CO levels and are designed to be used during smoking cessation programmes. The NHS has a smoking helpline, as does Quitline. Many people anxious to give up, I might say most, hope to achieve their aim by a slower and therefore less painful process than any cold turkey method, and prefer to attempt it by cutting down the number of cigarettes smoked. ASH—Action on Smoking and Health—warns that that is a pointless strategy for people concerned about their health. Apparently, the belief is that cutting down lulls would-be quitters into a false sense of security, with the result that they draw more deeply on the fewer cigarettes that they have allowed themselves. Dismissing that method, ASH says that it is just a different way of consuming the same drug. Similarly, smoking low-tar cigarettes simply leads to smokers inhaling eight times the amount of nicotine and tar than is stated on the packet.

So we come to hypno-and psychotherapy. What results are achieved by self-hypnosis, for instance, I cannot say. I have no experience of that method, but I hope that other noble Lords speaking in the debate will be able to give more information on it, particularly on the effects and the success rate. The same goes for experience of the inhalator, patch and gum therapies.

An organisation called Goldmoor offers a self-hypnosis programme called "Mind power" that claims to handle various kinds of stress. The Allen Carr is more convincing—to me, at any rate—with its boast of having 40 clinics in 18 countries and having treated 20,000 smokers in the past year. One is told that a trained therapist conducts a group of up to 20 people, and the session lasts for four to five hours. Smokers are encouraged to smoke as much as they like during sessions. At the end, they smoke a final cigarette and then, rather dramatically, I suppose, throw their lighters and remaining cigarettes into a pile at the front of the room. The therapist focuses on the reasons why we smoke, rather than why we should not. A combination of psychotherapy and hypnotherapy is used, with the aim of removing the smokers' belief that the habit provides them with any sort of genuine pleasure or crutch. Feelings of sacrifice and deprivation that may ensue from giving up are, in theory, removed, and the ex-smokers suffer neither fear nor pain from their loss.

On what seems to me a far lighter note, the British Heart Foundation, which runs an enthusiastic and dedicated anti-smoking campaign, has converted the popular Internet tetris game into an anti-smoking therapy. Apparently, when playing the game for the three minutes that it would usually take to smoke a cigarette, the player sees how many fatty deposits he or she can stop clogging up a section of artery. The idea is that the game distracts the player from his or her desire to smoke. I am afraid that my experience teaches me that the slight stress and challenge of the game would be more likely to lead one to reach for a cigarette.

Finally, there is the option of just giving up cold. It is hard. "Will-power" is an expression almost totally gone from our usage. It needs to he revived. We have become accustomed to expecting help with everything and doing little on our own. I can say only that I have never talked to anyone who, having given up, regrets it, or to anyone who feels no improvement in his or her health from having done so. Meanwhile, the world awaits a harmless potion that in a single dose and at one magic swoop will take away the craving to smoke.

Which therapy does my noble friend favour? Do Her Majesty's Government prefer a particular method as the safest, least likely to carry serious, troublesome side effects and the most efficacious?

8.3 p.m.

Baroness Gale

My Lords, I thank my noble friend Lady Rendell of Babergh for bringing this important subject before us tonight.

Every day, 450 children in Britain start smoking cigarettes. One in three girls aged 15 smokes, and most smokers start in their school years. Nineteen per cent of 11 year-olds in England have tried smoking. Children and young teenagers get addicted to nicotine, and the addiction can be as great as that of adults. If they decide to give up, where do they turn?

There are many good school-based programmes. Most are based on educating children about the danger to health and ensuring that children do not smoke at school. All that is very good in making children aware of the problem, but for children who smoke regularly there does not seem to be as much help and support given as there is for adults. One good organisation, called Quit offers advice to adults and to children and young people. It is one of the best that I have seen. It gives help and support to young people, such as a telephone helpline, counselling by working in groups during lunch hours at school and speaking in the same language as young people.

Recently, I read an article in the press that revealed that research showed that children as young as eight were smoking six cigarettes a day. Dr Nick Lupini, a GP in Llanelli, says: I have seen children of eight who smoke half a dozen cigarettes a day. When you have children as young as eight smoking cigarettes something needs to be done". He goes on to say: The prescription of nicotine patches would only happen as a last resort in these cases, and we would try other methods first. The real problem is children getting hold of cigarettes, not nicotine patches". I had the opportunity of speaking to Dr Lupini last week. He told me that, although children may smoke at a young age, they were, rarely heavily addicted and they only occasionally smoked. A bigger problem was teenage girls who smoke". Nicotine replacement products can be prescribed to children by GPs to tackle the problem of cigarette addiction, although some doctors have questioned the practice, as they believe that it might pull children further into the grips of addiction. From what I gather, there appears to have been no research into the effects on children and young people of the use of nicotine replacement therapies. There is a need for more research into the most effective way of helping and supporting young people and to see how effective therapies are for this age group. One report that I read recently said that research in the field was in its infancy.

A piece of research on young people, which was commissioned by ASH and carried out in July 2000, illustrated how difficult the problem was. The research, carried out by KSA Associates, showed that cigarette smoking retained a strong appeal among young people and that social pressures to smoke were strong. For many young smokers, the thrill of flouting the rules by buying cigarettes under age and smoking them at school seems to be part of the appeal of cigarettes. The research also showed that young people who wished to smoke had little difficulty in obtaining cigarettes. They know which shops will sell cigarettes to under-16s. Many young smokers rely on older friends to buy cigarettes for them, or they buy cigarettes at school, obviously from their school friends.

Underage smoking is a huge problem and there are difficulties in giving effective help and support to children and young people who would like to give up. I welcome the initiative by the Welsh Assembly on smoking cessation programmes for young people. Between 2001 and 2003 eight pilot adolescent smoking cessation projects were held in Wales. Because of the success of those projects, the National Assembly for Wales has won funding worth £221,000 from Europe to co-ordinate a Europe-wide adolescent smoking cessation programme. As a result, an initial conference is being held in Cardiff today and tomorrow. Representatives from 14 European countries will be attending and the aim is to support projects in eight countries, including Wales. This is a great initiative and should provide much-needed information.

I am sure that the Government are doing all they can, but unless we can persuade children and young people that smoking is not a good idea, how will we be able to reduce the number of adults who smoke?

8.8 p.m.

Baroness Finlay of Llandaff

My Lords, I too am grateful to the noble Baroness, Lady Rendell of Babergh, for raising this topic. We are not here to debate whether people should give up smoking, or indeed whether they should ever start, but whether there are measures that are effective.

I would suggest that it does not really matter what method someone uses to quit, providing of course that it is safe. There seems to be one single factor that determines the outcome, and that is the motivation to quit. People have to want to quit. They need to realise that they have a problem and to want to change their behaviour. It is at that point that pressures from society come in so strongly. In the clinical scenario, the unique opportunity of a clinical consultation may provide the teachable moment in which a person confronts the reality of their situation, but that depends on having some evidence of damage or potential damage to show them.

Much work has been done on behaviour change based on the "trans-theoretical model". It recognises the brick wall of trying to persuade someone who does not see the need to change to make the change, and the importance of maintaining change when it occurs.

Smokers can be thought of in groups covering certain stages. The first is the pre-contemplation stage, covering the kids who think it is cool to smoke. Those young people are not going to stop. They may then move into contemplation, thinking that perhaps it is not so cool when they cannot run as well as they could, or that they are coughing because of the cigarettes. The next step is key, that of preparation and beginning to think about stopping. That is followed by the action to stop, where the different therapies and support come in. Lastly comes the difficult stage of maintenance.

Motivation to stop smoking can be assessed accurately with three simple questions: do people want to stop smoking for good; are they interested in making a serious attempt to stop in the near future; and are they interested in receiving help with the quit attempt? Once the decision to quit is made, it seems that nicotine replacement therapy helps, in particular for those who had a high nicotine intake through their cigarettes. It also helps to identify heavily dependent smokers.

Student teaching in both medical schools and nursing undergraduate curricula is woefully inadequate, but the curricula are full and I suggest that it is probably at the postgraduate stage that the skills to help people stop smoking should be learnt. Pack cover messages probably do not have any effect; they just raise general awareness so that with hindsight people are aware of the risks they have been taking for a long time.

In the USA, studies have suggested that youngsters who smoke have higher levels of feelings of stress and depression, so smoking in young people in itself may be a pointer to mental illness in teenagers. So how do we discourage youngsters from ever starting on the road to nicotine addiction? A group of 14 year-olds from Caen in northern France and their teacher have come together to put on a forum of theatre vignettes in schools to get groups of parents and children to think about not smoking. They play a scene of kids smoking outside school in the morning, followed by a scene of two of them at home that night. The audience is invited to volunteer to take over the role of any character and act out what they think should be done, and the scene evolves. Interestingly, it is the youngsters, not their parents, who call for firm discipline and a zero tolerance culture. While the parents feel unable to confront their children, the children themselves seem to be pleading for strict rules so that they know where the boundaries are.

But the youngster in love seems to be able readily to quit if their loved one insists on it. That is a pretty powerful tool in getting people to stop smoking. Being in love is a therapeutic measure.

Passive smoking is known to damage health. I shall not go through all the background, but the figures from New York show that if there is a culture of not smoking, it makes quitting easier. Around 100,000 New Yorkers have now stopped smoking, and it is estimated that 300,000 smokers in the UK would stop completely if smoking was banned in public places.

We have to ask why so many nurses smoke. I would suggest that there is a sub-culture at work. But things can change. At my medical school, of the six porters, five were smokers two years ago. Since then I have given each quitter a box of House of Lords chocolates when they have given up for three months. The nonsmokers also get House of Lords chocolates to encourage them to stay off. I suggest that our gift shop is just as good as nicotine patches, but it is becoming a bit expensive for me as I am rolling the programme out to the canteen and the staff at Cardiff Central station.

Unfortunately the record of the tobacco industry is not good. The "Latin Project" is a sad tale of undue and undisclosed influence on the part of the tobacco industry. Therefore please can we have a ban on smoking in public places? It should be viewed as a therapeutic measure. Wales wants to do it. This is not about politics or power struggles. Banning smoking in public places is a preventive therapeutic measure.

8.14 p.m.

Baroness Hayman

My Lords, I join the general approval for and gratitude to my noble friend Lady Rendell for introducing this debate. She has rightly focused on looking at what works in terms of smoking cessation, rather than the damage that smoking does. However, as chairman of Cancer Research UK—an interest of which I remind the House—I believe that it is important that we focus on the truly horrific fact that smoking is responsible for a third of all cancer deaths in the United Kingdom each year, equating to 46,000 deaths in 2002, and that lung cancer kills one person every 15 minutes in the United Kingdom.

Lung cancer is an extremely difficult cancer to treat in the majority of cases. It is also an extremely easy cancer to prevent in the majority of—if not all—cases, by preventing people ever taking up smoking in the first place, and cessation of smoking for those that do.

Earl Russell

My Lords, I am most grateful to the noble Baroness, but I do not think she needs to persuade smokers that smoking is dangerous. Most of us who have been or are smokers know it. What she needs to do is to persuade smokers that life without smoking can be safe. That is a lot harder.

Baroness Hayman

My Lords, the noble Earl is absolutely right. My dear father used to say that it was easy to give up smoking: that he had done it hundreds of times. He died, not of lung cancer, but of bladder cancer—a cancer that is related, as are many other cancers, to smoking. I believe as the noble Baroness, Lady Finlay, said, that knowledge about smoking, as well as knowledge of the dangers of smoking, are tremendously important.

I know that the noble Earl is sometimes gloomy about the ability to persuade people to give up smoking successfully, but there are now 12 million people in this country who are ex-smokers and who have been convinced that life without smoking is worth while. That is a very important and encouraging fact. But I take the point that we need to know what is effective in this area. We need to have proper research that gives us the evidence on which to base strategies.

That is why I support not only the work that is founded on looking at the biologies of cancer or at developing new therapeutic targets in order to treat cancer, but also the very important behavioural research that seeks to understand the motivation for taking up smoking in the first place and looks at effective strategies for changing that.

There is very interesting research going on in Oxford, where Dr Robert Walton is investigating the molecular basis of nicotine addiction and how a person's genetic make-up influences whether they become a smoker and how easy they find it to give it up. That is the sort of research that will help to inform the counter-preventive strategies of the future and lead to more tailored and therefore more effective smoking-cessation aids. I am afraid falling in love is not a cure for everybody, nor an option that is open to everybody.

It is tremendously important not only that we conduct long-term trials on smoking cessation, but also that we are willing to share that evidence with the developing world. If there is one thing that is enormously sad when looking at countries in the developing world as they get richer, it is that more and more people smoke. They are then building up epidemics for the future and will have to go through the same learning curve that we have gone through in public health. That would be an absolute tragedy. We know the dangers, we are beginning to know some of the strategies that are effective in countering smoking, and we ought to be sharing that knowledge internationally.

8.18 p.m.

Lord Acton

My Lords, unlike my noble friend Lady Rendell of Babergh, who I congratulate on this Question, I will give my case history. I have given up drinking, smoking, gambling, swearing, pudding and coffee. Smoking was infinitely the hardest.

I started smoking at my colonial Rhodesian school when I was 12. The big boys smoked and the tough boys smoked. I was puny, and smoked hoping that I would be thought big and tough. Nearly all of us 10 Acton children smoked. The advertisements told us that smoking was grown-up. The economy depended on tobacco. We smoked box after box of 50 Matinee cigarettes. In a joking voice, cigarettes were sometimes called "coffin nails". We ignored that voice and our farmhouse was a blue haze.

Thus prepared for life, I departed for university in England. Down the years, cigarettes were my constant companions.

In 1988, following the advice of the noble Baroness, Lady Finlay, I fell in love and, aged 46, I married an Iowan. The social climate of that American mid-west state was fiercely anti-smoking. My wife banished me to the basement to smoke. At a dinner, I soon learnt that you could not smoke in other people's houses. I asked to smoke in the living room and then the television room and received a firm "No". Taken to see the car, I asked to smoke in the garage, and again got a "No". "I suppose the car will get cancer", I muttered furiously, and went out into the snow to smoke.

Gradually things changed. Everyone I met seemed to have given up smoking, even the most hard-boiled of mystery writers who seemed a natural smoker if ever there was one. Cigarette packets had a warning from the Surgeon-General that "Smoking can damage your health". I began to wonder if possibly he did not have a point, and then would hastily smoke two cigarettes to rub out the thought.

A doctor, originally from Glasgow, told me that he had given up smoking in the 1960s because of the proven link with lung cancer. There was a smoking room at that Iowa city party. "Look at that ashtray", he invited. I looked—really looked—at that ashtray overflowing with cigarette stubs. "What filth are you putting into your lungs?", he asked. I could not get that ashtray's image out of my mind. Finally, I went to an editor friend and poured out my thoughts. She summarised them. "You love your wife; you're very happy. Do you really want to kill yourself with cigarettes so as to be naughty?".

On 2 January 1991 I had lunch with my doctor friend. I told him that I doubted if I could stop smoking. He uttered the immortal words, "If you really want to give up smoking, you can do it". He recommended nicotine chewing gum, Nicorettes. After lunch I threw away my box of cigarettes and never smoked again.

But it was tough, very tough. The craving was constant. The Nicorettes were a blessed relief, but how I pined for the real thing. I ate far too much; my concentration waned; my temper deteriorated. On the other hand, my wife glowed with happiness and friends congratulated me. Somehow I got through that first year. Whenever I nearly gave in I would cling on to those words, "If you really want to give up smoking you can do it", and I would resist temptation.

After a year, with difficulty, I gave up my Nicorettes and switched to chewing gum. I believe that I have compulsively chewed more gum in your Lordships' Library than anyone else in history. Then my dentist forbade chewing gum as a peril to my teeth.

Fourteen years have gone by and I never think or dream of smoking. My experience shows, first, that a social climate hostile to smoking helps; secondly, that the support and encouragement of family and friends helps; thirdly, that the image of an overflowing ashtray with the slogan "What filth are you putting into your lungs?" helps; fourthly, that health warnings help; and, fifthly, that analysing the underlying reason you smoke helps. Like the noble Baroness, Lady Finlay of Llandaff, I believe that doubting that one can succeed is the greatest barrier to giving up smoking. So, sixthly, the words "If you really want to give up smoking you can do it" should be engraved in gold and stressed to every smoker who comes to the National Health Service for help.

8.23 p.m.

Baroness Massey of Darwen

My Lords, I thank my noble friend Lady Rendell for instigating the debate and for her masterly summary. Smoking is the subject of endless speculation. As someone once said, it is now proved beyond doubt that smoking is one of the leading causes of statistics.

If smoking is so harmful, why do people do it? Like the noble Baroness, Lady Hayman, my question to the Minister is: what evidence is there for what helps people to stop smoking? I am not convinced that therapies are the whole answer. In my family we have an expert on giving up smoking; he has probably tried everything. I have several friends who have attempted to give up; many with success, some not. One used to use patches; take the patch off to have a cigarette and then replace it. Giving up is highly individual and nearly always difficult despite incentives. People seem to think that they could give up if they wanted. A cabaret song went something like this: My teeth are all yellow and so is my tongue, I breathe through a kipper, they call it a lung, but I'll give up the habit. I will even yet, when I've had just one more cigarette". I know that a significant incident in life can precipitate stopping smoking. Long before I knew that I was pregnant with our first child, I gave up smoking, alcohol, tea and coffee. Clearly, my body was telling me something. Many women and men give up when they have young children. People give up after health scares, but some resume. Smoking is partly a public health issue and partly a personal issue, linked sometimes to therapies. Smoking is about addiction and risk taking. Many young people experiment and take risks such as smoking, drinking or drug taking, and stop the behaviour as they mature. Some do not. Some become addicts and addiction is difficult to break, as we have heard this evening.

I will briefly discuss hard-drug taking and drug treatment. I declare an interest as chair of the National Treatment Agency for Substance Misuse. We know that drug treatment works and that treating people for drug misuse saves a lot of money to all systems, including health and criminal justice. Treatment has to be readily available and suited to individuals, taking into account their lifestyles and mental states. Treatment can be a long process. I have heard users say that stopping is not the problem. Staying off drugs is the difficult bit. Therapies do work to help people stop using drugs, and so does the support of family, friends and communities, which was reflected in the comments of the noble Lord, Lord Acton.

There are parallels between drug use and smoking, but there are also differences. Smoking is a common social drug. I am sure that anti-smoking therapies can work, but they work better if they are supported by family and friends, once a person recognises that they need help. I said earlier that smoking is partly a public health issue. Public health is influenced by economics, social climate, campaigns, the media, education, advocacy and the law, as well as public services. In other words, health is not simply an individual issue.

In considering smoking cessation, I would like to say a word or two about social climate, campaigns, education advocacy and the law. I suspect that they may influence giving up smoking as much as therapy. Education and preventive measures designed to put people off starting unhealthy habits have had uncertain success rates and are difficult to evaluate. Making smoking unacceptable is beginning to happen. I can remember when cigarette advertisements implied wellbeing, toughness and sex, depending on whether or not you were on a horse. More and more people are insisting on not having to be near smokers. Health campaigns have become tougher. Helplines are frequently given alongside the deterrent to stop.

Last week a report from New York stated that a huge increase in cigarette tax and a ban on smoking in bars had cut the number of adults smokers by 100,000. New York City experienced the biggest decline anywhere in one year. Those who did not stop cut down by 13 per cent. A professor of health care put this down to a threefold attack—raising taxes, making it harder to smoke indoors and promoting cessation. Therefore, public health messages, legal imperatives and social climate seem to be powerful means of influencing health behaviour. If we can add suitable therapies, this holistic and multi-faceted strategy is the one most likely to succeed.

8.29 p.m.

The Countess of Mar

My Lords, if noble Lords do not mind, I should like to speak in the gap. I was notorious in this House for smoking 40 cigarettes a day, presumably reeking like a kipper and all the things that go with cigarette smoking. I wanted to give up. I had terrible problems with pleurisy, pneumonia and various other complaints. However, what I needed was something to spur me into giving up. Someone asked me to look into chemicals in perfumes—noble Lords will know that I am concerned about chemicals. I saw an article about aromatics in tobacco. I looked at the website and found five pages about extremely toxic chemicals.

Indelibly printed on my mind is the time of 10.15 on 15 March— the ides of March—2000. I have not had a cigarette since. What I did was to use nicotine patches—and nicotine lozenges for the periods when the patches did not meet the bill. I went through a programme with nicotine patches and kept on with the lozenges for about 10 months or longer. Then, like the noble Lord, Lord Acton, I reverted to nicotine chewing gum and he and I have probably kept Wrigley going ever since.

The spur was the support of a noble Lord who wrote the date down in his diary. He was—and still is—an inveterate smoker and he did not believe that I would give up.

Another spur was a very nice Labour Whip who promised me a glass of champagne after the first year and a glass of champagne after the second year. Then she realised that it was getting a little expensive so we have had no more champagne.

The third spur is the amount of money that I have saved. My bank balance is fit and flourishing and I am now able to give money to charity that I would not have been able to do before. I no longer smell like a kipper, I am fit and healthy and I am delighted to promote anything that would stop smoking.

8.31 p.m.

Lord Addington

My Lords, there are certain debates in which noble Lords join in even though they feel totally unqualified to so do.

The noble Countess may have been one of the greatest smokers in your Lordships' House, but my noble friend could challenge her on that score.

I stand here as the good boy in class, the one who did not smoke because he thought it was tough—probably because he was more scared of what his mother would do to him if she found out.

The serious point that comes across is the fact that there are two legalised and traditionally approved-of drugs in our society—alcohol and tobacco. But any use of tobacco damages people. Nicotine-dependent dried leaf damages people in all circumstances. It is probably the most addictive—and most easily addictive—of all the drugs that we consume, one that we have ingrained in our society and which we will have to push out by inches.

The story of the noble Lord, Lord Acton, shows that if a person is in the right social environment it can be very easy to try to quit. I say "try", I do not go through the process. If people are in a society where regular smoking is not encouraged, they do not do it so often and they are less likely to start.

I would like to go back a few years, when many more people smoked. The cigarette was a wonderful marketing tradition. It was one of the great marketing coups when people stopped smoking pipes and starting smoking cigarettes, because they are so much more social. How many chat up lines started with the offer of a cigarette? A couple of friends and I discussed how quick people had to be with a lighter to break in to a conversation with a girl. All these things were there and have been removed, largely by making sure cigarettes are, first, more expensive and, secondly, not consumed in public. That is one of the greatest things we have done. The Government must do everything that they reasonably can do—and, of course, enforce—and we have to apply social pressure.

The second and most important part of this debate is tackling those groups where smoking is deeply ingrained. They tend to be the lower-income groups that can least afford it, where both parents smoke, the children smoke and the house has a thick blue fog around it.

In a short debate like this I am fortunately not going to have to go through information with which I am not as familiar as I should be. But a Government who have introduced a Minister for Public Health have got to take very seriously that commission. They must support those who are going to guide and give counselling to those who are smokers. They have to inject money into communities whose members have traditionally gone to doctors only as a last resort.

These are people who do not read the diet fad books or take herbal remedies. These are the people who are going to be the most difficult ones to touch. This is probably a set of sociological clichés by today's standards. They are people who did not have long-term objectives, who thought of "now" as what they have. They do not have the tradition of going long term and worrying about their health. These are the people that we have to get hold of. It is so much easier for what used to be called the middle class to do this. In the environment in which they find themselves, the disapproval and the knowledge is there.

If we decide that we are going to ban smoking in bars and restaurants in this country, we will have taken the first step towards improving that the social environment. However, it will not help those who are already smoking if they simply stand outside and consume cigarettes at a frantic gulping-it-down rate outside those buildings. It does not really help those consume cigarettes outside offices.

We must get the support services in place and active. They must be activated through health workers, since if health workers point people in the right direction, they will take the advice—or at least they stand a better chance of taking it. We must do that sort of work and become involved with those parts of the community where smoking is most deeply engrained.

Can the Minister give us some direction about the programme and what guaranteed funding it has in the medium term? That is one of the problems, because preventive health therapy is not engrained in National Health Service culture. What is happening here? This is a programme with which the Government must be asked to take action. I hope that if they do so, we shall not have to address this subject again in at least the medium-term future.

8.36 p.m.

Lord McColl of Dulwich

My Lords, I, too, thank the noble Baroness, Lady Rendell, for introducing this debate. Only a cynic would believe the story of a patient who asked his doctor, "Will I live longer if I stop smoking and drinking?" and was told, "No, you won't live longer but it will seem longer". Of course, he was wrong. Sir Richard Peto has estimated that smoking will cause 450 million deaths world-wide in the next 50 years. Of that number, 180 million of these could be saved if there was a 50 per cent reduction in smoking.

There is a ray of hope, in that 70 per cent of smokers would like to give up. How can they best be helped to escape from this lethal and anti-social habit? The reason why it is so difficult to give up smoking is because the nicotine in the smoke is so strongly addictive. When the victim does stop completely, he can experience craving and withdrawal symptoms, which are so real. It is important to emphasise that it is not the nicotine that is the major cause of smoking-related disease, although nicotine can have a direct effect on arteries. It is the 50-odd cancer-producing chemicals that are so lethal. Therefore it is rational to give nicotine to satisfy people's craving when they are making a serious effort to stop.

The National Institute for Clinical Excellence—NICE—recommends nicotine replacement therapy or the drug called Zyban. These will double the smoker's chances of giving up, but they are for smokers who seriously wish to stop smoking as part of an abstinent-contingent treatment—ACT. The smoker undertakes to stop smoking on a particular date, known as the target stop date. It is important that there is advice on how to succeed and an initial prescription that will last until two weeks after the target stop date. Second prescriptions should be given only to those who have demonstrated that they are making a serious attempt. If the attempt is unsuccessful, no further attempts are funded within six months, as a rule.

It does not seem to matter by which route the nicotine is given, whether it is by patches, lozenges, inhalers or chewing gum, so it seems reasonable that the choice is left to the individual. Zyban works by suppressing the region of the brain that gives the smoker a nicotine buzz when smoking a cigarette. It is therefore taken before the person starts to quit smoking, and is intended to put people off smoking by stopping them getting the hit from the nicotine. It also reduces the usual withdrawal symptoms of anxiety, sweating, and irritability.

The noble Baroness, Lady Rendell, asked about the side effects. Some users reported nausea, headaches, dry mouth and blurred vision, which are not too serious. The drug is not recommended for pregnant women, those who are breast feeding, epileptics, or those with liver diseases or eating disorders. Early trials have found it to be highly effective, especially when combined with an overall giving up strategy.

The fact that many nicotine replacement therapy products are available over the counter from pharmacies is clearly an improvement on the situation a few years ago when they could only be obtained by prescription. Has the Minister considered making them even more readily available from newsagents and other such outlets where cigarettes are so readily accessible? Diet and exercise should be recognised as having an important role.

The NHS smoking cessation service is now available across the country giving behavioural support to those who really want to stop smoking, providing one-to-one counselling or group sessions, depending on personal preferences. I understand that 500 new staff have been recruited for this work. Can the Minister tell us how many centres are actually working throughout England? Will she give us an assurance that the £138 million allocated for this service for the period 2003–06 will be spent on those services? As the money has not been ring fenced, how will the Minister ensure that PCTs do in fact spend it on smoking cessation?

Smoking is a lethal plague and anything that can be done to help its victims escape would be most welcome.

8.41 p.m.

Baroness Andrews

My Lords, like all noble Lords who have spoken in the debate, I am extremely grateful to the noble Baroness, Lady Rendell, for enabling us to have such a thoughtful debate. She took us on a fascinating journey around the various therapies, via dry lettuce leaves. Clearly, love is more effective than dried lettuce leaves. We have heard about the therapeutic qualities of chocolate and even the role of the Whip, which is something I suppose we should all think about.

In recent months we have had many debates in the House on smoking but this was an opportunity to address and to take a look at new issues. I am very grateful to noble Lords who have shared with us their often heroic struggles to give up smoking. In such instances, one personal experience is worth a million words, when we understand just how hard and difficult it was to meet that challenge.

There is no doubt that just as public concern about smoking is increasing, we have reached a crucial point in our strategy to tackle smoking. I should like to reassure the noble Lord, Lord Addington, in that respect. In 1998 we published the White Paper, Smoking Kills. That was a landmark in public policy. The action that followed has established the UK as a world leader in the field with our smoking cessation services.

We have reached another turning point as we embark on an exercise in public policy involving people in a unique way in the questions in the consultation document and, indeed, in giving such prominence to smoking in this context. The noble Lord asked whether we are serious about the issue. We are. We called our document Choosing Health. That is exactly what we mean. It indicates that every one of us bears a responsibility for our own health. The document asks specific questions about smoking: What else can the Government do to ensure that people don't start smoking and if they do to support them to stop?". and: Who else in society should be involved in helping people not to start smoking and supporting those who start, to stop?". They are pertinent questions.

I hope very much that this debate will be read by those compiling the responses to the public debate, because such a lot of very important information has been given tonight. I want to refer particularly to the excellent contribution of my noble friend Lady Gale in that respect. She raised the important issue of children who are sometimes outside the formal therapeutic structure but who in fact are so vulnerable. The figures in relation to children and young people are not as good as we would want them to be in terms of the response. So, our smoking cessation policies have long emphasised personal responsibilities.

My noble friend Lady Rendell asked me what therapies work; how we know what works; what we provide; and why we provide it. Indeed, these are important and timely questions. As the noble Baroness, Lady Massey, said, when we are talking about smoking, we are liable to think about and to deal with a lot of statistics—of which the most important is that there are 120,000 deaths per year from smoking. Of those deaths, the highest proportion occur in manual socio-economic groups. I think that the most important and encouraging statistic is that 70 per cent of smokers say that they want to quit. As the noble Baroness, Lady Finlay, said, they have to want to quit. That is what we have to work on when we devise our motivational strategies. Our job as a Government is to make sure that they have the right help at the right time in the right way.

The challenge lies, as many noble Lords have said, in the nature of addiction to nicotine. The noble Lord, Lord McColl, gave a very cogent account of the nature of that addiction. The Royal College of Physicians has described it as comparable to addiction in relation to hard drugs. Indeed the withdrawal symptoms are extreme, I understand, with the impact they have on people's inability to give up.

We understand about the degrees of dependency. The noble Baroness, Lady Hayman, talked about the Oxford research which is looking at why some people are more dependent—whether they are more susceptible or whether it is genetic. I hope we will see more research like that because the knowledge that this might provide will give us somewhere to go in terms of our future therapies. The noble Baroness made an extremely important point about the developing countries and what we can see in terms of the global figures, which the noble Lord, Lord McColl, used himself.

If our smoking policies are to be effective, we have to recognise the strength of the image of smoking, the strength of the addiction, and the power of ritual in helping people to break the cycle of dependency. That is exactly what we are trying to do as a Government—to come at it in both ways, to address the psychological and the physical dependency. We are the first Government to set up smoking cessation services as part of the NHS and by 2006 we will have spent £200 million. I can say to the noble Lord, Lord McColl, that the money is not ring-fenced because so much of the work to do with smoking cessation is to do with the other services that we offer throughout the NHS. I have no doubt that PCTs, knowing as they do of the cost-effectiveness of those services, will ensure that that money gets through.

We know that our smoking cessation services are successful because they are based on the knowledge of what works. That is the answer to the noble Baroness, Lady Rendell. They are based on motivational support and effective therapies. The motivational support comes through the trained motivators who are in the centres—I am afraid I cannot give an answer to the number of centres. We recognise the quality of training that personal supporters have, a point referred to by many noble Lords. That help combined with the pharmaceutical therapies themselves on a systematic and regular basis—the four to six-week strategies, and then the therapies that kick in and last nine to 12 weeks—is what is accounting for the success. Certainly, our two preferred therapies are based on the evidence of what works. That is a nicotine-replacement therapy—noble Lords have paid tribute to the effectiveness of that, whether it is in patches or whatever—and in Bupropion (Zyban). There is compelling evidence to show that those who use the smoking aids roughly double their chances of quitting. The fact that we have made it available over the counter is making the NRT more accessible, giving more choice, and making it easier to access without going through prescription. I do not know about newsagents—I think it is something I could take back to the department with some enthusiasm.

Importantly, we are finding that NRT is a popular choice. About three-quarters of smokers choose that, and about half of those succeed in quitting. With regard to Zyban, the noble Baroness asked me about side effects. That question has been partially answered by the noble Lord, Lord McColl. It is a very effective therapy, but it is available only on NHS prescription. It is a relatively new product and it acts on the part of the brain which governs cravings. There are known and documented side effects. Some are not serious, such as insomnia and dizziness, but there is a very small chance—one in 1,000—of seizures and other side effects that are well known. Doctors would certainly screen their patients for those side effects.

Since Zyban was first marketed, it has been closely monitored by the Medicines and Healthcare Products Regulatory Agency and our own committee on safety. A number of steps have been taken to highlight Zyban's profile and maximise its safe use. We have put out strengthened warnings as a result of that monitoring. We have issued new dosage guidance, advising a slower increase. All that has been done by the Committee on Safety of Medicines. There has been a noticeable fall in the reporting rate of suspected ADRs since the titration was changed.

Zyban has also been the subject of a referral to the European equivalent of the CSM, the Committee for Proprietary Medicinal Products. It importantly advised that the balance of risks and benefits as an aid to smoking cessation remains favourable. That is consistent with the most recent advice provided by the CSM, and we obviously continue to keep Zyban very closely monitored by the medicines regulatory agency. The recommendations of the National Institute for Clinical Excellence in 2002 were that both NRT and Zyban should be used as first-line treatments. It reminded us that they are among the most cost-effective of all treatments.

We have that combination of therapies because we know that it works. When that is combined with counselling, we can increase the likelihood of quitting almost fourfold. In answer to the noble Baroness, Lady Gale, some of those quitters are young people. Because we have based our responses on what we know works, we do not provide hypnotherapy or acupuncture on the NHS although we are not hostile or indifferent to them. There is good evidence to show that they can work effectively as complementary methods, and can contribute to the package of care. We say that anything that the doctor thinks would work should be tried, provided that the patient is willing to try it.

Several noble Lords, including the noble Baroness, Lady Massey, drew attention to the fact that the therapeutic strategies take place in a context where education assumes a much more important role. There are much bolder and bigger messages on cigarette packets, and much more intelligence going into schools and the places where young people gather. When we come to our public policy statement on public health, we will ask questions of the very wide public audience about whether the Government should pass a law to make all enclosed workplaces and public places smoke-free. What about restaurants? What about pubs and bars? We look forward to some of those answers, because that will take the public debate a very long way forward.

Of all that we have heard this evening, I highlight the noble Lord, Lord Acton, simply saying that the most effective advice was, "If you really want to give up smoking, you can do so". I would like to leave the debate with that, as it was a particularly inspiring message. I am very grateful to all noble Lords who have spoken in such a wide-ranging and thoughtful debate.