I’m very disappointed in the section on cessation contained within the UK Department of Health’s new tobacco control strategy. There are several problems with the DoH’s ideas on cessation (and I’ll have more to say about them in future posts), but one of the most significant is its claims about how to quit smoking most successfully.
The strategy document says, “Those who are most successful in quitting use a combination of behavioural and medicinal support.” (p. 11) The only support for this rather extraordinary assertion is an unpublished report by West entitled, “The smoking pipe: a model of inflow and outflow of smokers in England.” But this source, which is a single page spreadsheet, provides little support for the claim about cessation. More troubling is that the DoH’s claim about the best way to quit smoking fails the most basic test of evidence-based medicine: it is contradicted by much of the published literature.
Lee et al (“Factors associated with successful smoking cessation in the United States,” American Journal of Public Health 2007), using data from the National Health Interview Survey 2000, report that 76% of successful quitters (for 7-24 months) stopped at once or went cold turkey (without assistance), as compared with 12% who used nicotine patches or gum. Ferguson et al (“Unplanned quit attempts – results from a US sample of smokers and ex-smokers“, Nicotine and Tobacco Research 2009) found that most of those who quit smoking without planning didn’t use either behavioural or medicinal support, and, most crucially, these unplanned attempts to stop were twice as successful as planned attempts. In fact, even in studies where smokers were provided continuous pharmaceutical interventions (e.g. use of a nicotine patch for six months), Schnoll et al (“Effectiveness of extended-duration transdermal nicotine therapy,” Annals of Internal Medicine 2010) found the one year abstinence rate was only 0.8% of the sample. This compares with unaided quit attempts that yield one year abstinence rates of between 3 and 11%. (Gritz et al “Unaided smoking cessation: great American smokeout and New Year’s Day quitters,” Journal of Psychosocial Oncology 1989).
Finally, it is difficult to reconcile the DoH’s use of West to support its claims about how to stop smoking successfully given West’s own research published in the BMJ. West and Sohal, (“Catastrophic pathways to smoking cessation: findings from national survey,” British Medical Journal 2006) in a survey of English smokers and ex-smokers, report that “a substantial proportion of attempts to stop smoking are made without any previous planning and, surprisingly, that unplanned quit attempts have a greater chance of succeeding.”
Why is any of this surprising, particularly given the consistently dismal record of long term success from pharmaceutically-assisted smoking cessation? As the American Cancer Society observed before the incursion of Big Pharma into the nicotine business, “Over 90% of the estimated 37 million people who have stopped smoking in this country…have done so unaided.” (Amercian Cancer Society Cancer facts and figures 1986)
Despite the DoH and the pharmaceutical industry’s promotion of pharmaceutically-aided cessation, the evidence suggests that unassisted cessation, not behavioural and medicinal support, is the method used most often by those who quit smoking successfully. Perhaps, the only people who find this surprising or dismaying are those in the pharma-nicotine industry.
Both physicians and their patients have an unqualified right to expect that the DoH provide scientifically accurate and objective information about smoking and tobacco control policy. The DoH has failed both the profession and the public in its claims about smoking cessation.
Patrick Basham is author of “Butt Out! How Philip Morris Burned Ted Kennedy, the FDA & the Anti-Tobacco Movement” and is coauthor of the bestselling “Diet Nation.” He has taught tobacco regulation and other health policy courses at Johns Hopkins University and has spoken on tobacco policy at universities and conferences around the world. Dr Basham is founding director of the Democracy Institute and is a Cato Institute adjunct scholar.