Just Say Nicotine (Maintenance)
by Jerome Beck

Amid the ferment surrounding the tobacco settlement and state lawsuits and their concern with preventing youth smoking, the plight of smokers unable or unwilling to discontinue their dependence on nicotine has received little attention. Nevertheless, the social landscape in which addicted smokers find themselves has been undergoing profound changes. Perhaps none have been more significant than the series of technological, corporate and regulatory developments which have brought the nation to the brink of a new market for long-term nicotine replacement and/or maintenance. Regardless of whether anti-smoking advocates deem this desirable, tobacco users find themselves presented with a growing number of nicotine delivery options. In their excellent review of the rapidly evolving market for nicotine maintenance, Dr. Kenneth Warner and colleagues acknowledge that, "For many health professionals, contemplating competition between the tobacco and pharmaceutical industries for long-term nicotine users will generate a sense of moral repugnance. Like it or not, however, this competition will continue to develop, barring extraordinary regulatory measures..."⁽²⁾

Numerous studies testify to the inability of many smokers to quit even when they are stricken with lung cancer, emphysema, heart attacks, and other smoking-related di seases.⁽⁵⁾ The familiar refrain of the tobacco industry notwithstanding, research clearly reveals nicotine to be on a par with, if not greater than, any of the other drug addictions.⁽⁸⁾

Nicotine Replacement Therapies (NRTs)
The rationale for long-term nicotine maintenance is legitimated from a public health perspective which recognizes both the intractability of nicotine dependence for many individuals, and the low toxicity of nicotine relative to many of the other constituents contained in cigarette smoke. The idea of providing smokers with less harmful nicotine delivery options is not a new one. Health professionals have been advocating for alternative forms of nicotine replacement for over three decades.⁽²⁾ A nicotine-containing lozenge appears to be on the immediate horizon.⁽¹²⁾

Although still too early to tell, regulatory changes permitting over-the-counter (OTC) sales of nicotine gum and patches in 1996 have a number of potentially significant treatment implications. Pharmaceutical company advertising campaigns for these OTC products already exceed $100 million.⁽¹³⁾ In addition, the TRDRP 1999 Call for Applications asks prospective applicants and other readers to ponder the research implications regarding whether such products might "become an alternative nicotine delivery system for life and not just a process whereby people wean themselves from smoking?"

Beyond this, research and advocacy are greatly needed to ensure the successful development, approval and implementation of a rational nicotine policy informed by public health concerns. In sharp contrast to the status quo, such a policy would provide a level playing field for assessing the relative safety and efficacy of various nicotine options. As Warner and colleagues conclude: "The absurd irony of the contemporary nicotine regulatory environment must be reversed: new pharmaceutical products currently face a long and expensive marketing approval process, while the most dangerous nicotine-delivery devices ever invented, tobacco products, are introduced and sold without regulatory impediments."