Performance of English stop smoking services in first 10 years: analysis of service monitoring data

NHS Stop Smoking Services: How NOT to run a quitting program

7 September 2013

The analysis by West and colleagues of performance of NHS Stop Smoking Services (SSS) from 2001 through 2010 is troubling. No improvement in program rates in more than a decade (Table 1), "medications" being forced upon quitters at unprecedented rates (91% during 2010/11), a dismal one-year rate of only 15 percent after NHS poured more than £1 billion into cessation during the decade reviewed,[1] clearly, the primary beneficiary of NHS SSS has been the pharmaceutical industry.

Between 2000 and 2012, NHS spent £1.2 billion on smoking cessation (£647.8 million on services and £562.9 million on approved quitting products)[1] with, as I'll show, nearly zero return. Accepting the authors' data and calculations, by my calculation, NHS is spending £7,416 ($11,561) for each 1 year ex-smoker in excess of quitting over would have occurred anyway; what the authors term program "impact" quitters.

While no relevance beyond cost versus use, as director of WhyQuit, a leading abrupt nicotine cessation site (cold/smart turkey), during the past year we spent a total of $91.68 (our annual web-hosting charges) in attracting 2.3 million unique visitors who generated 34.8 million site requests. In contrast, NHS spent £153 million for smoking cessation, in serving 816,444 quit attempts,[1] 85 percent of which failed.

I submit that "medication" is undercutting successful SSS cessation. For a host of reasons, including blinding concerns so great that they forced resort to active placebos containing small amounts of nicotine for at least 15 years,[2] clinical NRT efficacy failed to transfer into real-world effectiveness.[3]

As evidenced by a July U.S. Gallup Poll, most successful ex-smokers are quitting cold turkey.[4] In fact, all approved quitting products combined account for only a tiny fraction of U.S. cessation (8%). Imagine nicotine gum, after 40 years and billions in marketing, only being credited for 1 in 100 successful ex-smokers. On this point, NHS would be wise to demand an independent UK population quitting method effectiveness assessment.

Why would NHS again spend £31 million on replacement nicotine, when year after year 4-week data show NRT users failing to prevail over those quitting without it? Keep in mind, that at 4 weeks, receptors in the brain of the SSS cold turkey quitter have already re-sensitized, down-regulated and fully adjusted to functioning without nicotine, while the NRT quitter has another 4 weeks of nicotine use before attempting to adjust to natural dopamine pathway stimulation. While it makes NHS declaring successful cessation at 4 weeks sadly comical, it may explain why the one-year rate in the 2005 Ferguson SSS study was only 15.2 percent for NRT quitters, while 25.5 for those quitting without it.[4]

If less than 10% of successful UK ex-smokers used approved products (as is the case here in the U.S.) what logic is there in using a fiction (100% use) in computing a make-believe control group in order to evaluate SSS performance? The authors acknowledge that the SSS 4 week cessation rate is actually not four weeks but instead a two week point prevalence rate ("service users were asked if they had smoked at all in the past two weeks" - see pg 2, Methods, paragraph 4).

That's important because the authors then make an apples to oranges comparison of the SSS point prevalence rate to a continuous cessation rate from the Hughes 2004 "relapse curve" study. To quote from the Hughes study, "Because our interest is in success on a given attempt, we examined prolonged abstinence with no grace period rather than point prevalence rates."[5] Also, although the authors suggest its use, I could not locate any four week data within the Hughes study.

Worthy of note, the Hughes study heaps praise upon the 1989 Cohen et al study, which examined and combined 10 unassisted control group studies involving more than 5,000 quitters (x3 the Hughes sample). While the Cohen study does not present 4 week rates either (a highly unusual cessation finish line), unlike the Hughes study, it does share a one-year unassisted point prevalence rate of 13.9%[7]

How meaningful is the SSS 15% one-year point prevalence rate if 13.9% would have succeeded on their own? I submit that NHS has absolutely nothing to lose and everything to gain by directing SSS counselors to study and give priority to sharing the art, science and psychology of successful abrupt nicotine cessation [8].

[1] HSCIC, NHS Stop Smoking Services Collection, http://www.hscic.gov.uk/stopsmoking

[2] Jarvis MJ, Raw M, Russell MA and Feyerabend C, Randomised controlled trial of nicotine chewing-gum, Br Med J (Clin Res Ed). 1982 August 21; 285(6341): 537–540 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1499070); Sønderskov J, Olsen J, Sabroe S, Meillier L, Overvad K, Nicotine patches in smoking cessation: a randomized trial among over-the-counter customers in Denmark, Am J Epidemiol. 1997 Feb 15;145(4):309-18 at page 312 (http://aje.oxfordjournals.org/content/145/4/309.long); and Campbell IA, Prescott RJ, Tjeder-Burton SM, Transdermal nicotine plus support in patients attending hospital with smoking-related diseases: a placebo-controlled study, Respir Med. 1996 Jan;90(1):47-51, at page 48 "Patients in the P [placebo] group received a transdermal formulation with a very low content of nicotine (13% of the active form), a dose which is conventionally felt to be too low to affect outcome." (http://www.ncbi.nlm.nih.gov/pubmed/8857326).

[3] 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;31:758-66 (http://www.ncbi.nlm.nih.gov/pubmed/16137834); Pierce JP, Cummins SE, White MM, Humphrey A, Messer K, Quitlines and Nicotine Replacement for Smoking Cessation: Do We Need to Change Policy?, Annu. Rev. Public Health 2012. 33:12.1–12.16 (http://www.ncbi.nlm.nih.gov/pubmed/22224888);

[4] Gallup. Most U.S. smokers want to quit, have tried multiple times. July 31, 2013. http://www.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx

[5] Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction2005;100(suppl 2):59-69. www.ncbi.nlm.nih.gov/pubmed/15755262

[6] Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction2004;99:29-38. http://www.ncbi.nlm.nih.gov/pubmed/14678060

[7] Cohen S, Lichtenstein E, Prochaska JO, Rossi JS, Gritz ER, Carr CR, Orleans CT, Schoenbach VJ, Biener L, Abrams D, Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves, Am Psychol. 1989 Nov;44(11):1355-65. http://www.ncbi.nlm.nih.gov/pubmed/2589730

[8] Spitzer, J Never Take Another Puff, 2002, free PDF book http://whyquit.com/joel/#book; Polito J, Freedom from Nicotine – The Journey Home, 2009, free PDF book http://whyquit.com/ffn/index.html; Carr, A, The Easy Way to Stop Smoking

Competing interests: Pro bono director of an abrupt nicotine cessation forum and author of Freedom from Nicotine - The Journey Home, a free PDF book which is also available through Amazon.

John R. Polito, Nicotine Cessation Educator

Director WhyQuit.com, 106 Aldrich Place, Goose Creek, SC 29445 USA

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