It's not a patch on sucking: For many smokers, the attraction lies less in the nicotine than in the oral gratification. Artificial cigarettes could be the answer, writes Rob Stepney

If smokers need something to suck, a substitute cigarette containing nicotine but little else may be the answer.

The current route for smokers wishing to give up - nicotine gum or patches plus standard anti-smoking advice and encouragement - is proving disappointing. Only one in five smokers wanting to give up are still not smoking a year after the start of their treatment, according to an overview of research published last January in the Lancet.

Dr Godfrey Fowler, author of the Lancet report, and head of the Department of General Practice at Oxford University, says it is important to remember that without any help at all, only around 1 per cent of those smokers would have given up. 'Nevertheless, even in achieving 20 per cent abstinence, the effect of current nicotine replacement therapies is relatively small.'

One reason for this is that there is more to smoking than nicotine. Having something distracting to do with the hands and mouth, especially at times of stress, is clearly part of the habit. 'As an ex-smoker, I am myself aware that the business of handling cigarettes is important,' comments Dr Fowler. 'People who have given up for years are still playing with paperclips and sucking pencils.'

To meet the oral needs of smokers will require the development of some form of artificial cigarette which provides both a nicotine fix and an opportunity for ritualised hand-to-mouth behaviour.

The recent emphasis on nicotine addiction has tended to sideline other elements in the tobacco habit. But a century ago, Sigmund Freud was well aware of the complex attractions of smoking. Considering the origins of his own compulsive smoking, he argued that stimulation of the lips was central to the habit's satisfaction.

Freud was a classic casualty of tobacco. Despite attacks of angina which started when he was 37, he carried on smoking. As he wrote to his physician, not for him the 'misery of abstinence with nothing lit between my lips'. Freud persisted with his 20 cigars a day for two decades after his first smoking-related cancer of the mouth was diagnosed and removed.

During this period, pre-cancerous growths in the mouth were popping up at the rate of more than one a year. Yet Freud demanded of his jaw prosthesis not just that it should enable him to speak and eat properly, but that it should allow him to suck well enough to smoke.

Freud's case provides compelling early evidence about the health risks of smoking and its grip on the psyche. He theorised that thumb-sucking was a substitute for the pleasure of suckling on the breast, and a manifestation of primitive sexuality. Children for whom the erotic significance of the lips was intense would naturally graduate to smoking in adulthood.

Psychoanalytic theories are notoriously difficult to test, and their central concern with sex may seem misplaced. But there is evidence that weaning experience does relate to later smoking habits. A Harvard University study from the Fifties found that smokers unable to give up had spent less time at their mothers' breasts than those who successfully quit. And a later study showed that first-born boys who were closely followed by a sibling went on to smoke more than others, presumably because they had experienced frustration during the oral phase of development.

Such findings are supported by clinical experience. Some years ago Joseph Buchanan, a Canadian psychoanalyst from the Ottawa Civic Hospital, noted clear evidence of an 'oral personality'. His obese patients showed substitution of one mouth-based activity for another: when dieting, they smoked more.

At the Institute of Psychiatry's Health Behaviour Unit in London, Professor Michael Russell has spent 20 years researching ways to help smokers to quit. 'Though the weight of evidence is that people smoke basically because of nicotine, other aspects of the habit are important,' he says. 'I believe sensory factors become rewarding primarily because they are associated with intake of nicotine. But there is certainly a biological predisposition to conditioning behaviours that involve the hand and mouth.'

With this in mind, Professor Russell strongly advocates the development of an alternative to smoking that provides nicotine and that feels like a cigarette. To reduce smoking's toll of death and disability, such a device would have to produce negligible amounts of tar (which leads to lung cancer) and substantially less carbon monoxide (which contributes to heart disease), and ideally none of the noxious gases responsible for chronic bronchitis.

In the Eighties, the US tobacco company R J Reynolds spent dollars 300m developing an artificial cigarette. Professor Russell thinks it came close to producing a device that would save thousands of lives. In the prototype, lighting a carbon ring heated a metal core around which tobacco was wrapped. Instead of being burnt, the heated tobacco gave off a smoke that consisted mostly of water vapour and droplets of the harmless oily liquid glycerine. The smoke contained nicotine, but only 10 per cent of the tar delivered by a conventional cigarette and some carbon monoxide.

'There were drawbacks,' says Professor Russell. 'Market testing showed the flavour needed to be improved, the amount of nicotine delivered doubled and the amount of carbon monoxide cut. But then such a device would very likely persuade people to switch from ordinary cigarettes.'

Unfortunately, research on artificial cigarettes has stalled. In the US, a House of Representatives sub-committee labelled the Reynolds product a nicotine delivery system, meaning it could not be marketed as a cigarette but would have to be treated as a drug subject to strict controls.

'That was a knee-jerk response: bureaucratic technicalities abetted by misguided pressure from health experts,' says Professor Russell. 'The climate will improve when people understand there is no good evidence that nicotine itself is harmful at smoking doses, especially when absorbed relatively slowly.

'Swedish people who smear ground tobacco inside of their mouths absorb as much nicotine as cigarette smokers but suffer no more heart and blood vessel disease than those who use no form of tobacco.'

If nicotine does not cause harm, there is no rational objection to providing it in a form that smokers find satisfactory, as long as the nicotine is not accompanied by the other elements in smoke that cause disease. Yet tobacco companies in general have paid little attention to purifying the drug they purvey - an attitude that could prove very short-sighted.

The technology of delivering nicotine virtually free from harmful tars and gases requires some further refinement, and the resistance of regulatory authorities must be overcome. But designing a truly less hazardous form of cigarette that provides both the drug and the sensory stimulation smokers need is the logical way forward for those who find themselves genuinely unable to forsake tobacco.

No Smoking Day is tomorrow.

(Photograph omitted)