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EDITORIALS: Tim Coleman, John Britton, and Jim Thornton Nicotine replacement therapy in pregnancy BMJ 2004; 328: 965-966 [Full text]

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Fetal nicotine feedings premature

John R. Polito   (27 April 2004)

Fetal nicotine feedings premature 27 April 2004
John R. Polito, Nicotine Cessation Educator 1325 Pherigo Street, Mt. Pleasant, SC, USA 29464 Send response to journal: Re: Fetal nicotine feedings premature	The author asserts the need to subject mother and fetus to "definitive randomised, placebo controlled, clinical trials of a range of doses and administration routes for nicotine replacement." Should we not attempt to solve NRT's clinical trial vs. real-world performance riddle before subjecting the fetus to elevated levels of a known mutagen that is capable of angiogenesis and produces its own carcinogen (NNK)? The California quitting survey (JAMA 09/02), the Minnesota health insurance survey (Health Affairs 11/02), the "Tobacco in London" survey (Smoke-Free London 06/03) and most recently the "Quebec 2000 Quit & Win" survey (Prev. Med. 05/04) all indicate no NRT advantage over those quitting without it. Could it be that randomized clinical NRT trials were fatally flawed prior to randomization by a basic expectation of receiving free nicotine and too many minds that could sense its absence? In one of the OTC patch studies (Sonderskov J 1997) their blinding survey found that only 18.3% of those in the placebo patch group believed that they had received the real nicotine patch. The authors admit that "the effect of such a blinding failure would probably be a reduction of the placebo effect." Unlike in NRT trials, in real-world effectiveness surveys, such as Quebec 2000, we get to observe a group who fully expected to abruptly end all nicotine use go head-to-head with a group that fully expected to engage of weeks or months of nicotine replacement. The Shiffman and Hughes March 2003 OTC NRT meta-analysis produced a dismal 7% six-month NRT patch and gum rate and a horrific placebo group rate of less than 4%. By contrast the Quebec 2000 Quit & Win contest produced a 34% six-month NRT patch and gum rate and a 34% rate among those who quit without using any form of aid. On the solution side, looking at the U.S. Clinical Practice Guideline and BMJ’s ongoing series the "ABC’s of smoking cessation," it becomes obvious that those studying cessation pharmacology have entirely ignored a wonderful and growing body of non-pharmacology science. Each puff of nicotine was my liver to bloodstream feeding spoon allowing me to skip breakfast and lunch for thirty years. If we don't teach the importance of early blood sugar stabilization, the caffeine/nicotine interaction, time distortion, maximum crave episode duration, the basic timing and sequencing of recovery, and instill a few basic recovery skills such as abandoning the big bite concept of measuring success only in terms of quitting "forever" while instead adopting a more manageable victory standard such as "one day at a time," then who will? Although surveys indicate that roughly 80% of expectant mothers planned on quitting within the next few years and that 70% wanted to quit now, the sudden news of pregnancy and deep concern for the growing life inside will likely make her feel forced and compelled into quitting. It deprives her of her dream of someday quitting on her own terms, on a day of her choosing, and for her own reasons. Instead of embracing the opportunity to accelerate her own long-held dream, she instead quits for the baby and even if successful will likely relapse within hours, days or weeks of giving birth. Sensing evolving priorities, pregnancy is a wonderful opportunity to help the expectant mother expand her pre-pregnancy dream to encompass her growing world. She needs help in overlaying her dependency history upon her future and the obligations of motherhood. Will her baby be greeted by mom's sweet smelling kisses or instead bond to the stink of the 4,000 chemicals constantly being deposited upon her face, hands and clothing? Forced to either breathe lingering clouds of toxins or watch mom depart at least hourly to tend and care for her addiction, is it mom's dream that her baby live a life constantly interrupted by damaging smoke and/or loves absence? She needs to see that quitting for herself allows her baby to inherit the fruits of her dreams. She needs to understand that unless she puts herself first that her baby's needs and dreams don't stand a chance. She needs to reflect in advance upon the power of one chemical to cause her to perpetually temporarily abandon the life she carries inside. It is a basic tenant of all drug recovery programs that the addict cannot quit for others but must quit for themselves. Helping her shift core motivations is also important is helping prepare her to successfully navigate up to three weeks of possible postpartum blues. The more challenging population will likely be the almost 20% of expectant mothers who had no plans of quitting and who probably have an image of smoking again as soon as the umbilical is cut. Laboring heavily under dependency denial, harm denial and/or recovery denial, her dreams and desires are buried beneath a thick protective wall of rationalizations, minimizations and/or blame transference that needs help in breaking down. Should we spend millions generating another batch of badly flawed odds ratio victories associated with feeding mother and fetus increasing levels of nicotine or can we first revisit and harmonize the early NRT studies with "real-world" results? The greater mystery in my mind is why those strongly advocating nicotine replacement refuse to fully explore nicotine cessation. Competing interests: Founder of WhyQuit.com, a free abrupt nicotine cessation education and support forum that accepts no funding or donations from any source.