If and butts about smoking cessationBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6171 (Published 27 September 2011) Cite this as: BMJ 2011;343:d6171
- Des Spence, general practitioner, Glasgow
What constitutes a conflict of interest? I should state that I started smoking from around the age of 15. To my shame, I have smoked on and off since then, sometimes stopping for a number of years. I am fortunate in some ways—I am not the sort of smoker who wakes at 3 am to have a cigarette, and I can go many weeks without smoking. Today I would be called a “social smoker,” a horrific misnomer to the anti-smoking lobby. Because smoking costs. I have witnessed the premature death and chronic morbidity associated with smoking. I wish I could explain why I still smoke but I can’t. Smoking is truly bad.
Doctors must support public health attempts to eradicate smoking, and in general practice there has been much focus on smoking cessation. This used to mean brief counselling from general practitioners and nurses, and perhaps a suggestion to buy nicotine replacement therapy (NRT) over the counter. But in recent times smoking cessation has become an industry, with large teams offering counselling (non-participation not an option) and prescribed pharmacotherapy. The supportive services in England cost £84m in 2010—a rise of £60m over the past decade.1 Medications used to help cessation—NRT, vareniciline, and bupropion—cost £66m in 2010-1.1 The irony is that merciless international corporations are making profits on both sides of the smoking divide.
These intensive and well organised services have been running for at least five years, with smoking cessation activity being underpinned by a strong research base. 2 3 In 2010-1 services in England were in contact with nearly 800 000 smokers, half of whom “quit.”1 This is truly a success story.
On closer scrutiny the facts are not quite as they seem, because the definition of successful quitting is not smoking for only four weeks. Patients who didn’t use pharmacotherapy had similar rates of quitting to those that did. Importantly, therefore, what are the long term outcomes for smoking cessation services in the NHS?
With the large numbers involved, smoking rates should be declining, but the national data suggest that smoking rates are in fact flat, changing little in the past five years,4 and contradicting the smoking cessation data. Furthermore the greatest reduction in smoking occurred between 1975 and 1995, a period before smoking cessation and widespread pharmacological treatments. Put simply, the smoking cessation research is not translating into real outcomes, in the real world. As every smoker knows, it’s not the stopping that’s the problem but staying stopped. And in hard times we revert to what we know, even if you know it is killing you. Supporting smoking cessation is a good thing, but is it time to do it differently?
Cite this as: BMJ 2011;343:d6171