Tuesday, February 21, 2006

Reliance on Pharmacotherapy in Smoking Cessation Questioned

A press release issued today by Truth for Healthy Living suggests that a reliance on pharmacotherapy as a smoking cessation strategy may be crippling efforts to help the nation's smokers quit.

Truth for Healthy Living founder, Dr. Richard Lovelace (a licensed clinical social worker), argues that there is so much reliance on the use of nicotine to help people quit smoking that the public health world has lost sight of the possibility that addiction itself is the problem, and not merely nicotine. He questions whether efforts would be more successful if focused on the underlying problem of addiction itself, rather than merely on trying to cover up the effects of nicotine withdrawal.

Moreover, Lovelace asserts, the reason why nicotine replacement has become the mainstay (and a dismally ineffective one) of treatment for smoking cessation is the influence of the pharmaceutical companies, especially their funding of anti-smoking organizations and programs.

Lovelace states: "Accusing tobacco sneakily blames smokers and keeps us from identifying addiction as the root cause of chronic smoking. Why? To take money from unhealthy or at-risk adults and from our children. ... While politically powerful individuals will deny making the wrong decision that now threatens the health of a great many youngsters and adults, addiction specialists may know better. One of them states, 'It'’s a major mistake blaming tobacco for people smoking cigarettes.'"

"Cigarette smokers ... must go without assistance that deals with the root cause of chronic smoking. Nearly all of them are going without. ... Why do addiction professionals who are licensed health care clinicians rarely help adults quit and help prevent teenage smoking when, arguably, they are the most qualified? ... Trained clinicians realize the enormous odds against gaining sufficient attention (little-enough resistance) from present and future '‘users'’ and pivotal support from influential groups so long as credibility is given to focusing on a plant instead of the problem. Don'’t overlook likely profit motives. For instance, accusing the tobacco plant instead of the addicting component legitimizes the making of huge fortunes selling more ways to take in nicotine."

The Rest of the Story

If you can get past a few ridiculous statements in this material (such as tomatoes being a drug and the contention that smokers who garden don't need to buy cigarettes), at its heart I think actually lies a quite reasonable, and possibly, very instructive argument.

If one looks at the various addictive substances and the way in which public health groups deal with them, one is struck by the seemingly obsessive focus in the tobacco control field on nicotine as the sole cause of cigarette addiction and on nicotine replacement products as the single most important and effective solution to this problem.

But the reality is that smoking is a lot more complex a behavior than simply a method of introducing nicotine into the body, and addiction to smoking almost certainly has psychological, and not merely physiological, components. As do virtually all addictive behaviors.

When I worked in a methadone maintenance clinic for two years, I treated patients with nearly every chemical addiction under the sun. And for all of these - with one exception - we provided psychological help: therapy or 12-step programs directed at the underlying roots of addiction. Even when providing methadone maintenance for heroin addicts, And overwhelmingly, the most effective approach to helping clients to actually overcome their addiction was 12-step programs, not merely replacement of the offending drug.

In other words, addiction was viewed as the root of the problem, and we had to deal with that. It wasn't simply an issue of finding out a way to replace the offending drug with one that was less offensive.

But smoking was the exception. Almost uniformly, the approach was to prescribe nicotine replacement therapy and leave it at that. And almost uniformly, the approach failed.

There is little question that nicotine replacement therapy is a dismal failure. While it may be true that it results in a statistically significant increase in treatment success, at least in the short-term, this represents a statistically significant increase over a dismal success rate. As Lovelace astutely points out: "Officials and their agencies give that conflicting, confusing message when suggesting it'’s a way to stop smoking cigarettes. They report or imply that nicotine is now a Food and Drug Administration approved 'medicine' that helps people, to a meaningful extent, quit permanently, when it doesn'’t. Referring to what agencies print when ... using public funds to help sell nicotine delivery methods, someone '‘doubling'’ his or her chances of quitting’ for good means going from little chance to still little chance... ."

Perhaps Dr. Lovelace is correct. Perhaps there is too much of an emphasis on nicotine as the sine qua non of smoking behavior and on nicotine replacement therapy as the sine qua non of smoking cessation interventions.

In fact, I have already expressed my own opinion on this issue, which is quite in agreement with Dr. Lovelace's basic point:

"My own feeling, based on my years of experience in tobacco control, is that pharmacotherapy in general is over-emphasized and that most smokers who quit successfully long-term are those who quit cold turkey without any particular pharmaceutical aids. It is also important to note that smokers who relapse after having tried NRT therapy tend to do dismally in future cessation attempts with NRT. All in all, I think that the benefits and importance of drugs in the smoking cessation process have been over-emphasized."

I have also reported the results of research which casts some doubt on the heavy reliance upon pharmacotherapy in the proposed national smoking cessation action plan. I think it's entirely possible that the putative effects of NRT therapy, if applied on a national level, have been considerably exaggerated and that the ability of the proposed smoking cessation plan to cause five million Americans to quit within one year, as claimed, may be overstated.

I also agree that funding of tobacco control researchers and practitioners by pharmaceutical companies does have a lot to do with the overemphasis on nicotine replacement therapy. As I suggested earlier, the chair of the committee that prepared the national smoking cessation action plan has a rather large conflict of interest in making pharmacotherapy the cornerstone of the plan because he "has served as a consultant, given lectures sponsored by, or has conducted research sponsored by GlaxoSmithKline, Pharmacia, Pfizer, and Sanofi-Synthelabo" and in 1998, he was named to a university chairmanship made possible by an unrestricted gift to his university from GlaxoWellcome."

There is a legitimate argument to be made, I think, that smoking cessation programs should rely more heavily upon an understanding of, and direct confrontation with, the addiction itself, and less of an emphasis on merely replacing the nicotine in order to prevent withdrawal symptoms. As Dr. Lovelace points out: "Once physically dependent, total abstinence and permanently is what works. Tapering off doesn't. Even one '‘hit'’ of nicotine -– no matter the delivery method - makes someone not yet in the recovery that'’s required for him or her to survive. Public officials declare and confirm that nicotine is addictive. Then they give the opposite message: it isn'’t."

I tend to agree. In many ways, I believe that the preoccupation with nicotine replacement therapy, spurred on by the infusion of pharmaceutical dollars into the tobacco control field, is causing us to lose sight of the actual root of the problem: the addictive state itself. And that is a shame, because it may be severely hampering our efforts to help smokers quit.

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