The power of the press in smokers' attempts to quit

Doctors propose, the press disposes

In April 2002, the National Institute for Clinical Excellence (NICE) released guidance on cost effective pharmacological treatment of tobacco addiction.1 This endorsement allows every health authority in England and Wales to provide nicotine replacement or bupropion for patients who are dependent on tobacco and request treatment. Whether smokers will ask for and receive these drugs depends on many factors. Two scenarios, from the United Kingdom and the United States, illustrate the struggle between the press and medical experts to investigate and report concerns about the safety of new drugs for smoking cessation and the effect this struggle has on reported attempts to quit smoking.

The NHS advanced the treatment of the tobacco dependence movement with three initiatives: a white paper that established a priority for the treatment of tobacco dependence in 1998,2 a national plan for expanded smoking cessation services launched in 1999-2000, and the approval of bupropion in 2000 and nicotine replacement in 2001 for inclusion in the NHS reimbursement scheme. The Royal College of Physicians also published a report urging all doctors to treat nicotine addiction as a major medical and social problem.3

A new era dawned when the release of bupropion hydrochloride, which is a non-nicotine agent and is available by prescription only, required a doctor's direct involvement in patients' attempts to stop smoking. But most doctors were not trained and do not feel competent to treat tobacco dependent patients,4 despite the information on bupropion they have received from the government and the pharmaceutical industry. The print and television media heralded bupropion as a wonder drug when it was released in 2000. Not surprisingly, after the announcement of reimbursement for bupropion by the NHS, smokers queued up in waiting rooms, expecting their tobacco addiction to vanish with this new pill.

The public enthusiasm changed abruptly in February 2001, when a London newspaper reporter published a series of articles that profiled a few dramatic reports of deaths in smokers using bupropion.5 Other newspapers and BBC's Healthcheck programme picked up the stories, and soon all of Europe heard about these deaths. Predictably, the number of people receiving prescriptions for bupropion declined from 29% to 21.5% from April to September 2001.6 The number of patients at the centres had increased every quarter from March 1999 to 68 000 in the first quarter of 2001. After this, the demand for treatment diminished and a third fewer smokers were treated six months later. If this rise and fall is simply due to new year's resolutions and a no smoking day on 13 March and not to the escalating negative media stories a similar decline should re-emerge in 2002.

The Medicines Control Agency officially maintains that the contribution of bupropion in the 58 deaths reported since June 2000 remains unproved, and underlying conditions, often tobacco related, may provide an alternative explanation in most instances. 7 8 In the agency's thorough review, the data on adverse events associated with bupropion are similar to data in published global clinical trials—there were no new trends or surprises.

The dramatic shift in public opinion is reminiscent of the media coverage six months after nicotine patches were released in the United States a decade ago. Doctors working in emergency departments reported to the United States Food and Drug Administration that many patients who were admitted for myocardial infarctions were using nicotine patches. The media reported the story widely.9 In contrast with the prolonged media attention in the United Kingdom about bupropion, however, the stories ended abruptly a month later after the Food and Drug Administration's decisive report that there was no increased risk of myocardial infarction associated with nicotine replacement.10 A subsequent trial showed that patches were safe to use specifically in patients with cardiac disease.11 Unfortunately, although the experts were convinced of the safety of nicotine patches, many smokers still believe the original media messages that “if I use a patch and smoke even one cigarette, I might have a heart attack.”

The report from the National Institute for Clinical Excellence sends a clear message about the efficacy and safety of nicotine replacement and bupropion in treating tobacco dependence—similar to the US public health service's clinical practice guideline of June 2000.12 Clinicians should give clear messages to their patients that it is much safer to use either of these drugs to help their attempts to quit than to continue smoking. Unfortunately, much damage has been done.

Medical and nursing schools, medical specialty training programmes, continuing professional development programmes, and medical journals should educate doctors and nurses about their crucial role in developing the skills to help their patients to give up tobacco.13 Tobacco treatment specialists and public health agencies need to refute the inaccuracies of the media and present a clear picture of the enormous problem of preventable disability and the 120 000 tobacco related deaths a year from the 13 million smokers in the United Kingdom.