Can you explain the target of your research?

The aims of my research on tobacco harm reduction are firstly historical. I’m interested in charting the origins and development of this controversial policy paradigm and the patterns of technological innovation associated with it.

My work concerns the version of tobacco harm reduction which recognises smoking as an addiction and which seeks to substitute smoke-free nicotine delivery systems for cigarettes. I’m looking deeper into the origins and history of this approach through interviews and archival research relating, for example, to the invention of Nicorette® chewing gum.

Why are you interested in this area?

While the consequences of smoking for health achieved public recognition at the beginning

of the 1960s with the publication of, for example, the famous Terry Report in 1964, the identification of smoking as a problem of drug addiction was still denied. Cigarette smoking had become so normal and commonplace by this time that it remained difficult to conceive of smokers as addicts like illicit drug users. Through my research I want to clarify further how key innovations treating and acting upon smoking as a problem of nicotine addiction preceded and partly triggered the basic research that finally confirmed the identity of smoking as a drug problem in the 1980s.

Sweden has played an important part in smoking substitutes, can you explain why?

In part, I believe this relates to the traditional high standing of medical authority in Swedish society. However, the invention of nicotine chewing gum in Sweden at the beginning of the 1970s was a key event. Ironically, I think the birth of nicotine replacement therapies (NRTs) in Sweden owed a great deal to the unique history of tobacco use in the country. Oral tobacco has always been popular in Sweden and its widespread consumption partly delayed the uptake of cigarette smoking at the beginning of the 20th Century.

How did competition help?

In my research I’m addressing how a form of technological competition developed between the tobacco industry and pharmaceutical industry in Sweden during the early 1970s over who could produce the most successful cigarette substitute. When the health consequences of smoking became increasingly apparent during the 1960s, Swedish moist oral

tobacco, so-called snus, already existed as a readymade substitute for cigarettes. The competition still continues to this day.

Was the tobacco industry involved in the development of these alternatives?

At first it looked as if the Swedish tobacco industry would take over the commercialisation of Nicorette® gum in the

mid-1970s. When initial attempts to register nicotine chewing gum as a medical product failed, the Swedish Tobacco Company and Leo Pharmaceuticals drafted a secret agreement proposing that the former take charge of the marketing and sale of Nicorette® gum.

Simultaneously, doctors across Sweden who had been given free supplies of the prototype gum to revive a smokers’ clinic movement dating back to the late 1950s continued to campaign for the registration of the gum as a therapeutic product. This campaigning eventually paid off as the therapeutic merits of the gum achieved recognition after much contention. Rather than being marketed by the Swedish Tobacco company, Nicorette® gum became firstly a prescription drug.

What are the latest developments in NRT?

An ever-expanding range of NRTs is increasingly available today over the counter in pharmacies and in general convenience stores worldwide. They are still marketed as firstly smoking cessation aids, but because relapse to smoking remains the most common outcome of their temporary use, they deserve recognition as functioning firstly as harm reduction devices.

Your research has led to an interest in the development of neurobiological models of addiction – what’s the connection?

Nicotine addiction remains different because it is not associated with the same intensities of pleasure and pain as for example heroin or alcohol addiction. Cigarette smoking is not intoxicating and nicotine withdrawal – although distressing – is hardly life threatening. Addiction is understood as a personal inability to control and inhibit an unhealthy impulse. This resonates well with the vision of addiction that neurobiologists have been advancing in recent decades. Neurobiology is currently loosening the close identity of addiction with drug dependence and investigating addictions as closer to obsessive-compulsive disorders than previously imagined.

Will these insights lead to future research projects?

Yes. I plan to continue looking at how recognition of nicotine addiction has helped to alter perceptions of addiction itself in future research.

Associate Professor Mark Elam describes how the development of Nicorette® gum could have turned out very differently and how its global success helped trigger basic research ending controversy over the identity of smoking as a genuine drug problem

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RESEARCH INTO THE impact of smoking has taken place across the world with many influential insights and developments originating in Sweden. In the late 1950s Stockholm was home to the first specialist smokers’ clinics to help smokers kick the habit, in some cases using drug replacement therapy. The global distribution of Swedish nicotine chewing gum in the early 1980s helped to set the stage for the US Surgeon General’s confirmation of smoking as a genuine drug problem in 1988.

In a fascinating new project building on archival research, the historical development of nicotine replacement therapy is being contextualised and reappraised by Associate Professor Mark Elam in an effort to assess the importance it had for the recognition of smoking as a drug problem. In particular the study looks at the controversial use of the same drug – nicotine – that causes people to develop a smoking habit to help them quit. The drug was only recognised as a poison at the end of the 1960s.

TWO!PRONGED APPROACH

Since 1950, there have been two basic competing approaches to reducing the harms of smoking. The first has been presented as designed to reduce the toxicity of cigarettes and exposure to the most harmful constituents of cigarette smoke. The other recognises smoking as an addiction, and seeks to reduce the harms of smoking by the development of smokeless nicotine substitutes for cigarettes. Elam’s project addresses the second approach.

Nicotine addiction is different from addiction to heroin and alcohol because it is not associated with intoxication. It does however kill millions, firstly due to its connection with the repeated inhalation of carcinogenic cigarette smoke. This led researchers to envision the development of a cleaner and less contaminated drug delivery platform as an effective means to tackle the ‘smoking epidemic’.

DEFINING AN ADDICTION

In the early 1960s two influential reports by the Royal College of Physicians in the UK and the Surgeon General in the US established smoking as a cause of cancer while still downplaying the addictive nature of nicotine. This marginalisation of the role of nicotine in smoking was firstly challenged by the development of new and controversial treatment technologies based on the principle of nicotine replacement.

The idea behind Nicorette® chewing gum came from observations of submariners who substituted chewing tobacco for cigarettes while at sea. Thus, the Swedish pharmaceutical company Leo set about developing a replacement

therapy for cigarettes through imitation of oral tobacco. The inventor of Nicorette®, Ove Fernö, once claimed that transitioning “from chewing tobacco to chewing gum is not a large step”.

SNUFFING IT OUT

The brand name Nicorette® is derived from Swedish and implies nicotine (nico) in the right (rette) way. Mimicking oral tobacco, nicotine gum is designed to be alternatively chewed like chewing tobacco and ‘parked’ between teeth and gums like Swedish oral snuff known as ‘snus’.

The launch of Nicorette® gum was delayed when its registration as a medical product was denied in 1974. At this point, the Swedish

Nico-rights and

nico-wrongsA thought-provoking project at the University of Gothenburg

in Sweden is casting light on how nicotine replacement therapies

developed side-by-side with behavioural pharmacological

research that confirmed smoking as a problem of nicotine addiction

ORAL TOBACCO PORTIONS: A SWEDISH SUBSTITUTE FOR CIGARETTES INTRODUCED IN 1973

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ASSOCIATE PROFESSOR MARK ELAM

Tobacco Company almost took over its commercialisation. However, a question was raised in the Swedish Parliament about the risks that might follow from relatively uncontrolled sales of the gum. As a result, registering the gum as a medical product was reconsidered. Nicorette® was first sold in Swiss pharmacies 1978 and became a prescription drug in Canada, the UK and Sweden at the beginning of the 1980s.

A VITAL INSIGHT

New addiction problems typically arise when therapeutic drugs are widely exploited for recreational purposes. In his research Elam argues that, contrary to this established pattern, smoking won recognition as a genuine drug problem because nicotine replacement therapies started impinging upon recreational tobacco use.

Connections between Sweden and the UK were of vital importance for the establishment

of nicotine chewing gum as a therapeutic product. Michael Russell from the Addiction Research Unit at the Institute of Psychiatry in London collaborated extensively with Fernö during the 1970s and 1980s. For example, they jointly pioneered reliable methods for measuring levels of nicotine in the bloodstream in the early 1970s. Russell also played a vital role in organising randomised controlled trials evidencing the efficacy of nicotine gum as a smoking cessation aid. These trials were decisive, for example, for winning approval for Nicorette® gum in the US in 1983.

The successful innovation of nicotine chewing gum in the late 1970s led to an immediate explosion of more basic behavioural pharmacological research where the gum was also deployed as a research tool. This research, taking place first in the US, helped lay the scientific foundations for the 1988 Surgeon General’s report confirming the reality of smoking as the world’s largest drug problem.

A NEVER!ENDING STORY?

Elam argues that the face of nicotine replacement therapies is shifting once more today. Having gone from prescription drugs to over-the-counter drugs, an ever-growing range of replacement therapies is currently available in convenience stores. Thus, a path of development not immediately taken during the 1970s is now being taken.

There remain limits to how far the pharmaceutical industry is willing and able to go in promoting sales of an addictive drug like nicotine. In this respect the tobacco industry has more freedom to explore the potential of alternative nicotine products for creatively destroying the market for cigarettes. Once again signs of such development are already visible in Sweden. The new Zonnic® brand of fast-acting replacement therapies developed by people who originally worked on Nicorette® has been recently acquired by the US tobacco company RJ Reynolds. Research and campaigns to address smoking are likely to continue for many years, but undoubtedly the pioneering research taking place in Sweden has helped to begin to address the worldwide smoking epidemic.

Smoking won recognition as a genuine drug problem as nicotine replacement therapies started impinging upon recreational tobacco use

ALTERNATIVE STATES? THE SWEDISH AND BRITISH AFFILIATIONS TO SECOND WAVE TOBACCO HARM REDUCTION COMPARED AND CONTRASTED

OBJECTIVES

The project addresses the origins and development of nicotine replacement therapies in Sweden and the UK and the historically contingent identity of these therapies as temporary smoking cessation aids and/or direct cigarette substitutes. A particular focus is the closely related development of nicotine chewing gum alongside innovations in Swedish oral tobacco production during the early 1970s.

KEY COLLABORATORS

Centre for Social Research on Alcohol and Drugs, Stockholm University

Historical Archives of the Leo Pharmaceutical Company, Helsingborg, Sweden

FUNDING

Swedish Research Council

CONTACT

Associate Professor Mark Elam

University of Gothenburg Department of Sociology and Work Science PO Box 720 University of Gothenburg SE-405 30 Gothenburg Sweden

T +46 317864825 E mark.elam@gu.se

MARK ELAM has a PhD in Technology and Social Change from Linköping University, Sweden. As a postdoctoral researcher he was worked in both Sweden and Denmark on a variety of research projects spanning the fields of environmental and medical sociology as well as science communication. In future research he plans to look at how recognition of nicotine addiction has contributed to changing visions of addiction itself while also maintaining his interest in the development of the smokeless nicotine market as competition between pharmaceutical and tobacco producers currently intensifies.

SMOKELESS NICOTINE: AN OLD SWEDISH INVENTION WITH GLOBAL REACH TODAY

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INTELLIGENCE