anti-smoking drugs hystory

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Museum of the Royal Pharmaceutical Society, 2012

[email protected] www.rpharms.com/museum

Not to be reproduced without permission

‘Going Up In Smoke’ - Pharmacy and Smoking

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Since its arrival in Europe in the early 1500s, pharmacy and tobacco have had a long,

interesting, and at times contradictory, relationship.

This exhibition explores the development of this relationship, from the introduction of the

smoking of tobacco and other medicinal cigarettes to treat illness, to the development of

pharmaceutical products to aid smoking cessation.

When Christopher Columbus landed in

Cuba in November 1492, he saw local men

and women smoking what, he later found

out, was tobacco. Tobacco was imported

into Europe for the first time in 1556.

Europeans quickly tried this previously

unknown herb for recreational and medicinal

purposes. Between 1537 and 1559 at least

14 books mentioning medicinal tobacco

appeared in Europe. Aside from being

smoked, tobacco was used medicinally in

many forms including as an ointment, oil,

powder, syrup, gargle, and even as a smoke

enema. Sniffing powdered tobacco (i.e. as

snuff) was recommended to cure ulcers,

headaches and asthma. Tobacco was also

believed to treat shortness of breath, kidney

stones and stomach ache. During the Great

Plague of 1664 people smoked tobacco with

the belief that it would help them avoid

catching the disease.

Nicotiana Tabacum, L., lithograph by D. Blair, date unknown.

Tobacco: Some History

‘Going Up In Smoke’ - Pharmacy and Smoking

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Cigars. Coloured etching by Henry Heath, 1827. Published by S.W. Fores, London, 1827.

This caricature from 1827 takes a humorous look at people causing a nuisance by smoking in the street.

Even the children and monkey are smoking!

Image courtesy of the Wellcome Library, London.

Smoking tobacco for pleasure was already popular by the 1600s. However, in 1604 King

James I wrote a pamphlet criticising its use called A counterblaste to tobacco. He argued

that smokers’ internal organs were covered in soot and that they were wasting their money.

In 1828, two scientists, Wilhelm Heinrich Posselt and Karl Ludwig Reimann, isolated and

analysed the alkaloid in tobacco, nicotine, and discovered that it was a dangerous poison. In

spite of growing concerns, the recreational use of tobacco continued to increase. However,

the medical use of tobacco started to decline.

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This advertisement, published 100 years ago in the pharmacists’ trade journal The Chemists’ and

Druggists’ Diary, promotes the sale of tobacco products in pharmacies.

Advertisement, The Chemists’ and Druggists’ Diary, 1912

By the beginning of the 20th century many chemists were also tobacconists, stocking

cigarettes and cigars as an extra source of income. As scientific evidence about the health

risks associated with smoking tobacco became more conclusive, the relationship between

pharmacy and tobacco again shifted. In Britain, it took until 1962 for the publication of a

report, by the Royal College of Physicians, explaining that smokers were exposing

themselves to high risks of serious disease. The report, Smoking and Health, clearly indicted

cigarette smoking as a cause of lung cancer and bronchitis and argued that it probably

contributed to cardiovascular disease as well.

The publication of the report led to a ban on advertising cigarettes on television from 1965.

In 1987 the Council of the Pharmaceutical Society of Great Britain concluded that ‘members

be informed that they should not sell tobacco or tobacco products, including cigarettes

containing tobacco, from registered pharmacy premises’. However, you could still buy

cigarettes from pharmacies until 2001. A complete ban on smoking in public places was

introduced in England on 1st July 2007. A ban had already been implemented in Scotland

and Wales.

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Dutch Delftware tobacco jar, 1700 - 1799

This Dutch delftware jar labelled ‘Havana’ would have

been used in an apothecary shop for storing tobacco.

When tobacco was introduced into Europe in the 16th

century it was first used as a medicine. The ailments it

was taken for included wounds, headaches, catarrh,

chest complaints and childhood indigestion.

Arsenical Cigarettes

Manufactured by W. Martindale, 1904-1930

This cardboard box contains Arsenical

Cigarettes. The absorbent paper base of

each tobacco cigarette was impregnated with

the active ingredient arsenic. The Extra

Pharmacopoeia from 1928 states; “Arsenical

Cigarettes are made of paper impregnated

with sodium arsenate, so that each contains

3/4 grain (0.05 gm.) of the salt. The patient

ought to inhale the fumes deeply three or four

times”’. Bronchial and pulmonary conditions,

including chronic catarrhs, chronic phthisis,

spasmodic asthma, acute coryza, and hay

fever, were treated by smoking arsenical

cigarettes.

1. Tobacco as a Medicinal Treatment

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Why was smoking a medicinal treatment?

In the past medical professionals viewed smoking as an effective and legitimate medicinal

treatment. Primarily used to treat medical conditions of the respiratory system, smoking was

seen as one of the most effective ways to get the medicine straight to the lungs.

Aside from tobacco, other medicinal ingredients were smoked in cigars or cigarettes to treat

a number of respiratory conditions (or affections as they were then known), including

asthma, bronchitis, and hay fever.

Grimault's Cigarettes Indiennes

Manufactured by Grimault and Cie., Pharmaciens, Paris, 1897-1939

Grimault's Cigarettes Indiennes combined the active ingredients belladonna and cannabis Indica

extract. The cigarettes would have been smoked by the patient to relieve the symptoms of asthma,

bronchitis and coughs. Belladonna is powerful anti-spasmodic once used to treat spasmodic asthma.

2. ‘Asthmatic Cigarettes’ - Medicinal Cigarettes for

relieving Asthma, Bronchitis, and other Respiratory

Conditions (around 1870 - 1985)

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'Nutt Brothers’ Pectoral Cigarettes can be smoked by the most delicate lady or child'.

Leaflet advertising Nutt Brothers' Pectoral Cigarettes.

Manufactured by Nutt Brothers, 1877- 1893

Nutt Brothers' Pectoral Cigarettes were promoted as “A specific for Asthma, Bronchitis, and all other

Affections of the Respiratory Organ.' The ingredients are not known. However, the manufacturer’s claim

they are; 'Composed of renowned herbal materials, Warranted to contain no injurious ingredients'.

When smoking the cigarettes, the manufacturer’s advise; 'The smoke must be gently inhaled, and

allowed to flow through the respiratory passages ... so that the medicaments may have time to act...',

and that 'the cigarettes act most powerfully when smoked in a close [sic] room', with the patient sitting

quietly or lying down.

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'Jocigare' Anti-Asthmatic Cigares.

Manufactured by Wilcox, Jozeau and Company, Limited, 1941 - 1947

'Jocigare' Anti-Asthmatic Cigares are indicated on the box 'For the prompt relief of tightness of

breathing, shortness of breath, feeling of suffocation, and other distressing symptoms of asthma'. Each

cigar contains hyoscyamine (belladonna leaf alkaloids), powdered digitalis, and potassium nitrate. The

directions state; 'In smoking these cigarettes, inhale the smoke so as to introduce as much as possible

into the air passages'.

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The most common ingredient in asthma cigarettes is stramonium. Stramonium is the dried

leaves and flowering tops of Datura stramonium or Datura tatula. The medicinal action of

stramonium is due to the alkaloid hyoscyamine which relieves the spasm of the bronchial

tubes. In the treatment of asthma and other spasmodic respiratory conditions, stramonium

was given in tablets, mixtures, or smoked in cigarettes. However, by the early 1950s, the

smoking of stramonium in cigarettes was viewed by medical professionals as being of

limited value since the irritation produced by the fumes could aggravate bronchitis. Despite

this, stramonium cigarettes were manufactured until the mid 1980s.

Datura Tatula Cigarettes for Asthma

Manufactured by Savory and Moore, Limited. 1902 - 1931

Datura Tatula Cigarettes for Asthma were introduced by the manufacturer’s Savory and Moore in the

1870s as a remedy for asthma and bronchitis. Stramonium is the dried leaves and flowering tops of

Datura tatula. Savory and Moore claim on the packet; ‘The fumes of this Plant inhaled generally afford

instantaneous relief’.

3. ‘Asthmatic Cigarettes’ - Stramonium Cigarettes for

relieving Asthma, Bronchitis, Hay Fever (around 1870 -

1985)

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Potter's Stramonium Cigarettes

Manufactured by Potter and Clarke Limited 1941 – 1947

Potter's Stramonium Cigarettes were 'For the immediate relief of asthma, bronchitis, hay fever, and

spasmodic diseases of the respiratory organs'. The cigarettes contain 90% stramonium.

Potter's Asthma Cigarettes

Manufactured by Potter and Clarke Limited

1976 - 1984

Potter's Asthma Cigarettes, containing 98%

stramonium leaves, were 'For the relief of asthma

attacks and other spasmodic affections of the

respiratory tract'. The directions state; 'The smoke

should be drawn well into the lungs and retained

as long as possible, then expelled through the

nose and mouth’. Patients were advised; ‘Do not

exceed 6 cigarettes per day'.

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‘Smoking is a greater cause of death and disability than any single disease’;

The World Health Organisation

Smoking tobacco seriously damages the human body. There are around 12 million adult

smokers in the UK and smoking is still the largest preventable cause of premature illness

and death in the UK. One out of every two smokers will eventually die from a smoking-

related disease.

Smoking is associated with around 50 diseases today, including:

Coronary heart disease

Lung cancer

Stroke

Chronic bronchitis and emphysema

Shortness of breath

Increased coughing and sneezing

Gangrene

Reduced fertility

Defective vision

Pharmacy and Smoking Cessation

The Effects of Smoking

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Secret Remedies - Medicines for the Tobacco Habit 100 years ago

Consumer demand for anti-smoking treatments is not a recent

development. Even 100 years ago manufacturers were reacting

to the demand for preparations to help people quit smoking.

Their pharmacological effectiveness however is doubtful.

The book More Secret Remedies, published by the British

Medical Association in 1912, exposed the fraudulent claims and

revealed the ingredients of many proprietary medicines for the

first time. More Secret Remedies contains one anti-smoking

‘treatment’; Wood’s Cure for Tobacco Habit. This ‘cure’ consisted

of a complex system of 8 different tablets and pills to be taken

over a 72 hour period, a total of 125 doses; where after the

patient was guaranteed to be ‘cured’ of their addiction. The

British Medical Association was scathing in its criticism of the

preparation, since the tablets and pills only contained traces of aperients and tonics, and

three contained strychnine despite not being labelled a poison.

Victory Anti-Smoking Tablets. Manufactured by S.D. Ewen,

M.P.S., Dundee, 1950-1962

Promoted on the label with; 'Stop the tobacco habit', Victory Anti-

Smoking Tablets are a very early example of a pharmacist

formulating their own treatment to help patients give up smoking.

The tablets contain the active ingredients ferrous sulphate (iron

sulphate) and alum. Ferrous sulphate, an iron salt, was used in

the treatment of iron-deficiency anaemias. Alum precipitates

proteins and has an astringent action.

4. Early Anti-Smoking Treatments

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From the 1960s lobeline hydrochloride and lobeline sulphate were believed to be of value as

an anti-smoking deterrent. The pharmacological actions of lobeline closely resemble those

of nicotine. However, clinical trials of lobeline in the early 1960s led it to be considered by

the medical profession as being no more effective than a placebo as anti-smoking therapy.

Its use as an anti-smoking treatment had been withdrawn by the late 1980s - early 1990s.

Lobidan

Manufactured by Uni-Pharma Limited,

1961-1978

Lobidan tablets were indicated as a

'Smoking deterrent' containing 'Buffered

Lobeline'. The active ingredient lobeline

sulphate was used to reduce the craving for

nicotine and eliminate abstinence symptoms when giving up cigarettes. However, controlled trials of

lobeline sulphate (Lobidan) frequently found it to be no more effective than a placebo as a smoking

deterrent.

Antisol Anti-Smoking Aerosol.

Manufactured by Aerosmoke Limited, Newbury, Berkshire, 1967-1971

The Antisol Anti-Smoking Aerosol was used for administering the active

ingredient lobeline hydrochloride by means of an inhalation aerosol. The

recommended dosage was; 'Not more than 10 inhalations per day'.

Promoted on the packaging; ‘Lobeline is the nicotine substitute. Lobeline

smoke is the substitute for tobacco smoke'.

5. Lobeline Hydrochloride / Sulphate (1960 - 1990)

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Smokewatchers Anti-Smoking

Course.

Manufactured by

Smokewatchers, London, 1971-

1990

The Smokewatchers Anti-

Smoking Course contained;

Smokewatchers Aversion Therapy

Tablets, Nicotine Substitute

Pastilles, a Smokewatchers

Course Booklet and Instructions,

and a Smokewatchers Guarantee

Form.

The Smokewatchers Aversion Therapy Tablets contain silver acetate which produces an unpleasant

taste when combined with cigarettes. However scientists now believe there is little evidence that it has

any effect in promoting smoking cessation. The Nicotine Substitute Pastilles contained lobeline

hydrochloride.

Many people find nicotine cravings the hardest thing to handle about quitting smoking. Nicotine Replacement Therapy (NRT) products were developed to give patients the extra support needed to beat their physical addiction to nicotine. By easing the physical cravings, patients find it much easier to overcome the psychological side of giving up smoking. Treatment is usually required for three months and then gradually withdrawn. NHS research shows that people who use Nicotine Replacement Therapy products and the other licensed stop smoking medicines, used in combination with a local Stop Smoking Service are four times more likely to stay quit.

Is taking nicotine replacement therapy safe?

Nicotine Replacement Therapy (NRT) is relatively safe and is not just swapping one addiction for another. Unlike cigarettes, NRT does not contain tar, poisons or carbon monoxide like cigarettes do, so it doesn't cause cancer. It is absorbed into the body in a different way to the nicotine absorbed from cigarettes, and it is very much less addictive.

6. Nicotine Replacement Therapy (NRT)

(1989 - present day)

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NRT is currently licensed to be administered through chewing gum, transdermal patches, lozenges, sublingual tablets, nasal spray, or inhalator.

Nicotine Replacement Therapy – Transdermal patches

Nicotinell TTS30 Patches - Manufactured by Zyma Healthcare, 1996

Medical professionals believe nicotine replacement

transdermal patches are the easiest to use of all nicotine

replacement formulations and compliance is greatest with

this method.

Nicotinell Patches were designed in three sizes. As the

patient adjusted to not smoking he or she gradually

reduced the size of the patch. The large size higher

strength Nicotinell TTS30 Patches were for people who

smoke 20 or more cigarettes a day. Each patch contained

52.5 mg nicotine. When applied to the body, the nicotine in

the patch passes through the skin and into the body,

replacing the nicotine the smoker would normally get from smoking. The instructions state; ‘You must

not smoke whilst using these patches’.

Nicotine Replacement Therapy – Chewing Gum

Nicotinell mint chewing gum, 2 mg regular strength

Manufactured by Zyma Healthcare, 1996

Nicotinell chewing gum was to be chewed for up to 30

minutes when the patient felt the urge to smoke. The nicotine

released from the chewing gum is absorbed into the

bloodstream from the lining of the mouth, providing quick

relief from cravings. Regular strength Nicotinell chewing gum

contains 2 mg nicotine. Nicotinell chewing gum is also

available as 4 mg extra strength.

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Nicotine Replacement Therapy – Lozenges

NiQuitin.CQ Lozenges

Manufactured by SmithKline Beecham Pharmaceuticals

Ltd, 2002

NiQuitin.CQ lozenges containing 4 mg of nicotine were

intended; ‘For those who smoke within 30 mins of waking’. For

further support the manufacturers included a ‘Committed

Quitters Stop Smoking Plan’.

Nicotine Replacement Therapy – Sublingual Tablets

Nicorette Microtab

Manufactured by Pharmacia UpJohn, around 1999

Nicorette Microtab is a sublingual tablet containing 2 mg

nicotine. Rather than being chewed or swallowed,

sublingual tablets are dissolved under the tongue.

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What about electronic cigarettes?

‘Electronic cigarettes’, which administer nicotine in the form of a vapour, are an increasingly popular substitute for smoking cigarettes. However, electronic cigarettes are not currently licensed, or therefore regulated, as medicinal products. Only licensed medicinal products benefit from assurances of quality, safety and efficacy.

The Royal Pharmaceutical Society does not endorse the use of electronic cigarettes as a form of treatment as their use may not be in the interests of patients or the public.

Buspirone hydrochloride is an anxiolytic (anti-anxiety) agent, available only on prescription.

Although used primarily to treat very mild to moderate anxiety disorders, clinical studies in

the 1990s suggested that buspirone could be used to treat nicotine dependence. Some

clinical studies showed that in the short term buspirone could increase the number of

patients who were able to quit smoking. However it did not reduce the withdrawal symptoms.

By 2002 the use of anxiolytic (anti-anxiety) agents such as buspirone was no longer

recommended by medical professionals for smoking cessation.

Cox Buspirone Tablets 10 mg -

Manufactured by Alpharma A/S, 2001

These tablets contain 10 mg of the anti-anxiety

agent buspirone hydrochloride.

7. ‘Reducing the Anxiety of Quitting’ –

Buspirone hydrochloride (1996 - 2001)

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Bupropion hydrochloride is an anti-depressant, available only on prescription. However, in

smoking cessation, its action is said to be independent of its anti-depressant activity. It is

believed to act by increasing dopamine activity in the brain. It is given in a modified release

preparation, with treatment commencing 1-2 weeks before the patient attempts to stop

smoking, to allow steady-state blood levels to be reached. Treatment continues for a further

7-12 weeks. Bupropion has also been used with Nicotine Replacement Therapy, though

there is an increased risk of hypertension with this combination.

Zyban tablets - Manufactured by Glaxo Wellcome SA, 2000

Zyban tablets are a treatment to help patients give up smoking when they are addicted to nicotine. They

contain the active ingredient bupropion hydrochloride, in a prolonged release formulation. Patients start

taking the tablets while they are still smoking and set a ‘target stop date’ in the 2nd week of treatment.

This is because Zyban’s prolonged release formulation needs time to start working.

8. ‘The Anti-Depressant’ –

Bupropion Hydrochloride (1999 - present day)

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Varenicline is a non-nicotine drug treatment designed to help smokers stop smoking. It is a

prescription only medicine (POM). Varenicline works primarily in two ways. Firstly, it reduces

the smoker's craving for nicotine by binding to nicotine receptors in the brain, reducing the

symptoms of withdrawal. Secondly, it reduces the satisfaction a smoker receives when

smoking a cigarette.

Champix tablets

Manufactured by Pfizer Limited, 2011

The brand name of varenicline in the UK is

Champix. Pfizer, the manufacturer of varenicline or

Champix, claim that clinical research shows that

with Champix the odds of quitting smoking are

twice that of buproprion and four times that of

placebo.

9. ‘Reducing Nicotine Craving and Withdrawal’ –

Varenicline (2006 - present day)

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Stopping Smoking requires commitment and planning. Pharmacists are among the most accessible of healthcare professionals, with branches open in the high street at convenient times. Therefore pharmacists are ideally placed to offer the public advice and information about the benefits of stopping smoking and the support available.

Smoking cessation is the most common service provided by pharmacies in the UK and many stock the quitting aids available. Aside from offering advice on pharmacological treatments for smoking cessation, pharmacists also provide patient support, highlighting the importance of will power and commitment when giving up smoking.

Services available may include: -

Carbon monoxide testing: this can be beneficial in assessing a smoker’s

status providing a pre quit level and a post quit level four weeks later.

Checking for COPD (Chronic Obstructive Pulmonary Disease): the

spirometer device measures the volume of air expelled in the first second of

forced expiration.

Behavioral and lifestyle advice, advice on withdrawal symptom

management: the pharmacist can suggest other ways in which the patient

can improve their overall wellness.

Drug therapies: pharmacist’s offer informed guidance on the

pharmacotherapy available.

Promotional beer mat

Distributed by the National Pharmacy Association,

2007

This beer mat, promoting the services that pharmacies

offer in helping with smoking cessation, was distributed

around pubs by the National Pharmacy Association at

the time of the Smoking Ban in 2007.

10. The Role of the Pharmacist in Helping with Smoking

Cessation

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Promotional postcard, entitled 'Quit Smoking with Will Power', 2007

Produced to coincide with the introduction of the smoking ban in England on 1st July 2007, the card

promotes Lambeth NHS Primary Care Trust's stop smoking service and highlights the role pharmacists

can play in helping an individual stop smoking.

NHS Smoke Free Quit Kit

Distributed by the National Health

Service, 2012

To encourage members of the public to

quit smoking these kits are being

distributed free of charge through

pharmacies, and the NHS Smoke Free

website www.nhs.uk/smokefree. The kits

contain a wide range of pharmacological

and non pharmacological support tools and

advice to help individuals successfully

through the process of quitting smoking.

http://www.nhs.uk/smokefree

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Useful Websites

England - www.nhs.uk/smokefree

England - www.nosmokingday.org.uk

Scotland - www.canstopsmoking.com

Wales - www.stopsmokingwales.com

Smoking Cessation Support Services

http://www.nhs.uk/smokefree

http://www.nosmokingday.org.uk/

http://www.canstopsmoking.com/

http://www.stopsmokingwales.com/

anti-smoking drugs hystory

Education