Does nicotine replacement really help smokers quit?BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e450 (Published 18 January 2012) Cite this as: BMJ 2012;344:e450
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Competing interests: No competing interests
Alpert, Connolly and Biener's new population level study found that within the first six months of quitting that the odds of smoking relapse among heavily dependent quitters using nicotine replacement threapy (NRT) were 3.53 that of those quitting without NRT or professional help. That ratio declined to 2.62 within the first year of quitting, and held steady at 2.68 by two years.1 Heavily dependent was defined as having smoked within 30 minutes of waking + smoking at least 20 cigarettes per day.
Douglas Kamerow's January 18, 2012 BMJ editorial is entitled "Does nicotine replacement really help smokers quit?"2 Kamerow suggests that the Alpert study was not "well done" because "most importantly, we have known for a long time that people who quit on their own ('cold turkey') are different from those who need and seek help through counselling or drugs." "They may be less addicted, or have more willpower, or something else..."
It's ironic that Kamerow invokes NRT's current most favored failure explanation, the selection bias theory, when the above unmentioned Alpert findings contrast heavily dependent NRT quitters to heavily dependent non-NRT quitters.
It's also strange to at last read in print that cold turkey quitters truly are different from clinical trial placebo quitters, who joined seeking "medication." It's why quitting product marketing assertions that "your chances" are the same as a clinical trial placebo user's are both false and deceptive.
But Alpert's negative real-world NRT findings are far from alone. Nearly all population level studies since 2000 have found NRT no more effective than quitting without it.
Responding to my Freedom of Information Act Requests, the only population level quitting method study acknowledged as having been conducted by the USDHHS was the 2006 National Cancer Institute analysis by Hartman.3 Hartman found 9 month quitting rates among 8,200 quitters to be 14 percent among 1,766 NRT users, 12 percent among 311 using more than one type of NRT, and 16 percent among 5,428 non-NRT quitters.
A 2006 Australian study followed smoking patients of 1,000 family practice physicians.4 Among 2,207 former smokers, 88 percent had quit cold turkey, with cold turkey's success rate roughly double that of the nicotine patch, gum and inhaler, or Zyban.
Clearly, the world's most medication dependent cessation program is UK NHS Stop Smoking Services (SSS). Review of the program's facilitator training guide, the NCSCT Standard Treatment Programme suggests that medication use is all but forced upon participants. Medication use is urged while teaching the "not a puff rule," during discussion of withdrawal symptoms, during review of medication options, and in discussing quitting preparations.
What's missing from NHS facilitator training is any mention as to how most real-world quitters succeed, how SSS counselling or support can substantially enhance cold turkey success rates, or how even by week four of treatment, that UK NHS SSS program data consistently shows non-medication quitters doing as well as or better than NRT quitters, who still have another 4 to 8 weeks of treatment before attempting to adjust to natural brain dopamine pathway stimulation.6
Although long-term NHS quitting method data is treated as though top secret, there was one long-term study. Ferguson et al 2005 examined one-year SSS rates in Nottingham and North Cumbria. The sample shows just how forced medication use is within SSS. Among 47 non-medication quitters, 25.5 percent quit for one year versus 15.2 percent among 1,568 NRT quitters.
So, how do we explain 88 percent of Australian smokers quitting cold turkey while 93 percent of 2011 UK NHS quitters used medication? And at what price? If population level use of NRT is less effective than quitting without it, are quitters world-wide paying with their lives?
It's a question that begs investigation by non-conflicted researchers. When doing so, I recommend focus upon subgroups within non-medication and unassisted populations. Which subgroup method was superior? And what was the common thread among the method's successful quitters?
John R. Polito, JD - Nicotine Cessation Educator
1. Alpert, HR, Connolly GN, Biener, L, A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation, TC Online First (TC abstract), January 10, 2012
2. Kamerow, D, Does nicotine replacement really help smokers quit? BMJ 2012;344:e450
3. Hartman, AM, What Does U.S. National Population Survey Data Reveal About Effectiveness of Nicotine Replacement Therapy on Smoking Cessation? NCI, 2006 - Unpublished - Free PDF copy
4. Doran CM, Valenti L, Robinson M, Britt H, Mattick RP, Smoking status of Australian general practice patients and their attempts to quit, Addict Behav. 2006 May;31(5):758-66. PubMed abstract
5. McEwen, A, Standard Treatment Programme, 2011 NHS Centre for Smoking Cessation and Training. 2nd edition, ISBN 978-0-9565243-2-4, PDF Copy
6. The Information Centre, NHS Stop Smoking Services, NHS, Data from 2005 to 2012. Website link
7. Ferguson J, Bauld L, Chesterman J, Judge K, The English smoking treatment services: one-year outcomes, Addiction. 2005 Apr;100 Suppl 2:59-69. PubMed abstract
Competing interests: Pro bono director of a cold turkey nicotine cessation website.
Congratulations to Dr Kamerow for his balanced critique of the Alpert et al study. One additional but important problem with that study was that it did not study smoking cessation at all, but rather focussed on ex-smokers who had , "quit smoking within the 2 years prior to the wave 1 interview (‘recent quitters’)", and then followed them up years after they originally quit. Thus this was a study of long term relapse among people who had quit years earlier with different treatments. Both nicotine replacement therapy and counseling work by boosting the initial quit rate and it is not generally claimed that these (or any) treatments reduce relapse years later. So in addition to the weaknesses pointed out by Dr Kamerow, the findings of this study were entirely predictable and quite irrelevant to the question of whether nicotine replacement or counseling help smokers to quit.
Competing interests: JF has done consulting work for pharmaceutical companies producing smoking cessation medicines (e.g. GSK, Novertis, Pfizer, J&J etc).