Intended for healthcare professionals

Rapid response to:


“Catastrophic” pathways to smoking cessation: findings from national survey

BMJ 2006; 332 doi: (Published 23 February 2006) Cite this as: BMJ 2006;332:458

Rapid Response:

How to use behavorial findings to sell NRT

Professor West, your presentation was pure science until you decided
to taint and transform a stages of change rebuke into an NRT sales pitch,
based upon beliefs that are very likely as erroneous as those you just

I am at a loss to understand why you felt the need to convert a
behavioral finding into a nicotine patch commercial. Such boldness and
tenacity after openly declaring your pharmaceutical financial ties is
disburbing. I submit that this study should have stood on its own.

Professor West, the following issues beg research attention but it is
not in the pharmaceutical industry's financial interests to do so. I
submit that the following six conclusions are correct and challenge you to
disprove them.

1. Almost all successful UK and US quitters who have remained 100%
nicotine free for at least six months quit smoking cold turkey (80 to
90%). Conclusion: Pharmaceutical industry commercials and literature
which continue to suggest that quitting cold is nearly impossible are both
false and deceptive.

2. Conclusion: Placebo controlled NRT clinical studies were not
"blind" as claimed and their conclusions simply cannot be accepted as
science-based, especially in light of the fact that NRT has failed to show
any advantage whatsoever in all real-world surveys to date (see Mooney M,
et al, The blind spot in the nicotine replacement therapy literature:
Assessment of the double-blind in clinical trials. Addict Behav. 2004
June;29(4):673-84 and ). Nicotine is a
psychoactive chemical producing alert dopamine/adrenaline intoxication.
Any smoker with a quitting history has some degree of awareness of what it
feels like to have their nicotine removed and returned.

3. Conclusion: NRT clinical odds ratio victories over placebos were
not earned but by default. A significant percentage of the active group
had its expectations fulfilled and remained to benefit from study
behavioral elements that ranged from telephone contact, evaluation visits,
counseling, education and group or individual support, each of which have
their own proven efficacy. A significant segment of the placebo group had
its expectations of receiving weeks or months of free nicotine products
shattered and "most" placebo group quitters dropped out within the first
two weeks. In no clinical NRT study did researchers ever interview the
majority of placebo group which relapsed within the first two weeks, while
this group's assignment beliefs and relapse motivation memories were still
fresh and accurate (within the first month).

4. Nearly half of all smokers have now attempted quitting with over
-the-counter NRT products. Acknowledged GSK consultants conducted a meta-
analysis of OTC patch and gum studies and found that 93% of users had
relapsed to smoking within six months (see Hughes, JR, Shiffman, S, et
al.,A meta-analysis of the efficacy of over-the-counter nicotine
replacement. Tobacco Control, March 2003;12:21-27 ). Conclusion: Athough
one year OTC NRT cessation rates are a well kept industry secret, if
historic rates from 1 year clinical studies hold, roughly 96% of those
using OTC NRT as a stand alone quitting tool relapse to smoking within one

5. Only two nicotine patch studies have examined the odds of success
of second-time nicotine patch users, Tonnesen (April 1993, Addiciton) and
Gourlay (1995 August BMJ). In Tonnesen 100% of second-time users relapsed
within 6 months and in Tonnesen the rate was 98.4%. As the NRT quitter
use rate continues to climb this factor grows even more critical, yet
remains undisclosed by the pharmaceutical industry or its army of
consultants. Conclusion: Unlike with cold turkey quitting where the
odds of success increase with each subsequent attempt, the repeat NRT
user's odds of success dramatically decline.

6. One last NRT point relating to the December 2005 report to the
UK government that you co-authored, which led to a government brochure for
pregnant mothers which advises "Ideally you should try to give up smoking
without the use of NRT but if you can't manage this, you can use NRT. The
risks to your unborn baby are far less than from continuing to smoke. If
you have sickness or nausea NRT patches may be preferable to gum,
lozenges, tablets or inhalers."

According to Dr. Theodore Slotkin, one of the leading nicotine
toxicologists, "there is abundant evidence that the major problem for
fetal development is exposure to nicotine rather than other components of
cigarette smoke." Dr. Slotkin pointed me to the Sarasin study which found
fetal rat brain nicotine concentrations 2.5 times higher than the mother's
blood nicotine level when on continuous nicotine feed, such as would be
the case with the nicotine patch (see Reproductive Toxicology, 2003, 17:
153–162 ). Conclusion: UK fetal development is about to experience its
darkest era ever. Oh how I pray that you are right and that the world's
leading nicotine research toxicologists are wrong.

In closing I ask you to ponder the impression this study leaf with
readers. You identified 996 successful ex-smokers and your lead closing
recommendation was the nicotine patch. What would you expect them to
believe? If you have survey data indicating how the 996 quit I challenge
you to share it here. I submit that it will show that more than 900 of
them succeeded without resort to replacement nicotine.

John R. Polito
Nicotine Cessation Educator

Competing interests:
Editor of, the Internet's leading abrupt nicotine cessation resource.

Competing interests: No competing interests

28 January 2006
John R. Polito
Nicotine Cessation Educator
1325 Pherigo Street, Mount Pleasant, SC USA 29464