Worth the price? - underwriting smoking cessation

Governments across Europe are getting on board to help people stop smoking. Ross Campbell discusses nicotine replacement therapy’s underwriting implications

Smoke-free legislation was fully implemented in the UK in July 2007. By next year, all 27 EU member states should have banned smoking in enclosed areas.

Spain was the latest to comply and introduced one of the strictest smoking bans in Europe in January, taking earlier legislation enacted in 2006 much further.

Spanish smokers follow those in Poland and Greece as the latest to face a series of restrictions on tobacco smoking in enclosed public places backed by legislation.

The aim is to protect workers and the public from second-hand smoke, a known health risk. Studies appear to provide a convincing argument that there is a significant health benefit in restricting smoking in public areas.  

Meanwhile, restricting the freedoms of smokers for the public good generates increased social stigma that will, it is hoped, persuade more to seek help to quit permanently for their own benefit.

Spain’s National Committee for Smoking Prevention (CNPT) has released advice to smokers considering turning to electronic cigarettes to help them quit.

Nicotine Replacement Therapy

Nicotine is described as being as addictive in use as Class A drugs. Yet, despite its power, nicotine poses relatively little health risk in the doses obtained from tobacco smoke.

However, to extract the drug from cigarettes means smokers must also consume the tar released from tobacco as it burns. It is this, together with carbon-monoxide and the 4,000 known chemicals in tobacco smoke, that cause harm to health, smoking-related diseases and death. 

Cancer Research UK has called for nicotine replacement therapy (NRT) products to be made more affordable and accessible to people, while hoping for the opposite to occur in tobacco.

In response to the increased pressure to quit smoking that legislation brings, many tobacco consumers have turned to NRT.

Alternative sources of nicotine, such as patches or gum, help control and address their addiction. Such pure nicotine products are a safer vector for nicotine consumption and have the added aim of helping smokers quit permanently. 

NRT products are classed as nicotine delivery ­medicines and their content and use are highly regulated; for example, by the Medicines and Healthcare Products Regulatory Agency. This is in complete contrast to cigarettes, which are non-regulated.

To meet regulations and to protect consumers, all nicotine delivery medicines must meet agreed standards of efficacy, user safety and quality.

More recently, electronic cigarettes (e-cigarettes) that contain nicotine mixed with other ingredients have begun to be marketed.

Products aimed at aiding smoking cessation are becoming more plentiful. Advice from the NHS soothes concerns that NRT contain any toxic chemicals or cause cancer. 

In addition to listing nicotine gum, patches, nicotine nasal spray, micro-tabs and lozenges, the NHS also includes inhalators. The inhalator (e-cigarette) releases nicotine vapour or mist mixed with tobacco flavourings which is absorbed through the mouth and throat. 

Ingredients of inhalators include water and propylene glycol (PG) among others. PG has been rated by US health regulator, the Food and Drug Administration (FDA), as “generally recognised as safe” for use as an additive in some food and cosmetics.

Although, it is also used in diverse products, such as antifreeze and hydraulic fluid. 
Limited inhalation when using such products is unavoidable, but the FDA recommends it be avoided – however the smokeless cigarette is all about inhalation.

The FDA will regulate drugs containing nicotine that only purport to aid smoking cessation.

Interestingly, Potential Reduced Exposure Products (PREPS), such as e-cigarettes, are not endorsed by Cancer Research UK on the grounds that while users may reduce intake of certain toxic ingredients, they risk increasing consumption of others and that their use may even discourage quitting. 

Chemical company Dow reports that while there is no evidence that PG is a carcinogen, “exposure to [PG] mists may cause eye irritation, as well as upper respiratory tract irritation. Inhalation of PG vapours appears to present no significant hazard in ordinary applications.”

It adds: “However, limited human experience indicates that inhalation of PG mists may be irritating to some ­individuals. Therefore, inhalation exposure to mists of these materials should be avoided.”

NRT boosts the chances of quitting successfully. Tapered use of the medication (eventually to nil) is the recommended dose.

However, successful quitting requires beating cravings, withdrawal and habit. Part of the smoking ‘habit’ is the hand-to-mouth movement. An e-cigarette does not break this behaviour, so could prove a less successful quitting aid or may even maintain nicotine dependence.

Abandoning tobacco as a source of nicotine undoubtedly confers some immediate health benefits, but relapse rates are high. A 2009 study by the Centre for Tobacco Control say 75% of smokers abstinent at four weeks relapse by 12 months.
Smoker or non-smoker?

The justification for charging smokers higher base premium rates is not solely attributable to their habit. Smoking is a proxy for a number of risk factors that contribute to their higher mortality or morbidity.

One question is how to treat applicants who disclose using e-cigarettes from a smoker/non-smoker rates perspective. The answer is dependent on what is asked on the application form and how a ‘non-smoker’ is defined in the policy wording.

If the smoking question only asks “Have you smoked a cigarette in the past 12 months?”, technically a person who has switched to an e-cigarette may answer in the negative and accept a non-smoker premium rate in good faith. 

However, there would be problems validating their statement as they would test positive for cotinine, the metabolite of nicotine widely used by insurers as a measure of exposure.

Application questions that ask about all tobacco use may specifically include all nicotine products. So if the applicant is using any form of nicotine replacement, they are treated as a being a smoker.

The potential to differentiate between a true positive cotinine test from tobacco exposure and one derived from a person using an e-cigarette looks like a tough call to make. Cotinine can be detected in users of e-cigarettes with nicotine. 

Ideally, insurers should act in a consistent way and apply smoker rates to everyone with a positive cotinine test.

Sorting smokers from non-smokers is important for insurers that offer differential premium rates. An applicant declaring to be a non-smoker can be tested for the nicotine metabolite cotinine to verify their statement. 

Users of e-cigarettes, as other NRT products, test positive for cotinine and are not eligible for the lower rate.

Applying smoker premium rates to those with a continued intake of nicotine – albeit from an alternative source – ­factors in those smokers who have only recently quit and their high potential for relapse and applicants being economical with the truth.

While nicotine is being consumed, insurers cannot validate their ‘non-smoking status’ and should charge premiums appropriately.

E-cigarettes are battery operated and are based on a re-usable kit, but appear to offer an expensive alternative to the pure nicotine NRT products and, in some countries, even to cigarettes themselves.

However, they offer the sensation of ‘real’ smoking and may prove socially acceptable or even legal for use in public spaces where bans apply to ‘tobacco smoking’.

For some smokers, this may prove an attraction worth paying a premium for. That such a device could ultimately replace their tobacco smoking or lead to permanent cessation is a moot point.

Another reason for caution is that e-cigarettes of all types have not been in common use for long and so there are few studies to demonstrate their impact either on long-term health or quitting smoking.

Spain’s CNPT concludes that the nicotine content in e-cigarettes does not render their use effective in quitting and that the vapour is harmful to general health and therefore not safe for use in enclosed public spaces.

Ross Campbell is Chief Underwriter, Gen Re Life/Health Research & Development