Tuesday, November 01, 2011

Study Finds Cold Turkey Quitting More Effective than NRT, But Concludes the Opposite

According to a study presented at the 2011 CHEST (American College of Chest Physicians) annual meeting, physicians who recommend cold turkey smoking cessation are giving bad advice as they should instead recommend the use of nicotine replacement therapy (NRT) or other medications.

The study is summarized in a press release as follows:

"Clinicians frequently recommend patients stop smoking but do not always provide them with appropriate tools to ensure their success. Researchers from the Medical University of South Carolina in Charleston conducted a survey of 777 current and ex-smokers, asking questions about patient demographics, smoking status, smoking cessation attempts, physician recommendations regarding approaches, and methods used to stop smoking, as well as cessation treatments. Among current smokers, 66% were advised by a physician to stop smoking. A cold turkey approach was advised 19% of the time, while nicotine replacement therapy was advised 52% of the time, and medications were advised 40% of the time. Of those who received a recommendation to quit cold turkey, the success rate was less than 10% a year. Greater efforts may be required by clinicians to ensure patients receive appropriate evidence-based therapy for smoking cessation."

The study abstract concludes as follows:

"Patients report that that clinicians make inquiries regarding patient smoking status and recommend smoking cessation; however, it appears that many patients are given improper cessation techniques. According to participants, clinicians recommend a 'cold turkey' approach to smoking cessation in 19% of cases, but its success rate is less than 10% at 1 year. Based on the survey results, it is unclear if patient's are receiving appropriate information and/or education regarding smoking cessation therapy.

The Rest of the Story

Readers may be surprised to find out that the study, according to the abstract, actually found that cold turkey quitting is more effective than the use of the so-called "evidence-based" therapy.

If you read the results section of the abstract, you will note that the authors report the following finding: "Former smokers reported that they were significantly more likely to have attempted a cold turkey approach to smoking cessation (p<0.0001) and less likely to have tried evidence-based therapies to stop smoking compared to current smokers (p<0.0001). "

This finding indicates that successful quitters - the former smokers - were more likely to have used a cold turkey approach, while the unsuccessful quitters - the current smokers - were more likely than the quitters to have used "evidence-based" therapies.

In other words, these data provide evidence that cold turkey smoking cessation is more effective in achieving sustained smoking cessation than the use of NRT or other medications.

While I hold out hope that this is simply a typo and that the actual finding was the opposite, if not a mistake it means that the authors drew the opposite conclusion from what their data showed and suggests that they have some sort of bias in favor of medication over cold turkey quitting.

Interestingly, while the press release and abstract report that the cessation rate was below 10% with cold turkey quit attempts, neither reports the cessation rate with the so-called "evidence-based" approaches: NRT and other medication. This is a curious omission in a study that purports to have demonstrated that NRT and medication are more effective than cold turkey quit attempts.

Of note, these study findings are consistent with those of several previous studies which have also found that cold turkey, unplanned quit attempts tend to be more effective than planned attempts that often involve the use of medications (example 1; example 2; example 3).

The odd apparent discrepancy between the study results and the study conclusion may seem difficult to explain until one considers the financial disclosure statement at the end of the abstract. It states that all of the authors "have nothing to disclose."

However, a quick internet search revealed that one of the authors does indeed have an apparent conflict of interest, as he reports (elsewhere) having consulted for and received consulting payments from GlaxoSmithKline for helping the company market its Nicorette Fruit Chill gum. Though this financial relationship with the pharmaceutical company occurred in 2006, I explained last week why I believe it is still very much relevant for the reader of the present study.

If the published abstract is printed correctly, then the rest of the story is that the research appears to be biased, with an admonition against the use of cold turkey cessation that runs counter to the data presented in the paper itself. Moreover, there appears to be a significant financial conflict of interest among one of the study authors that is not disclosed in the paper and which I believe should have been disclosed. This author's history of a past financial relationship with Big Pharma and his apparently paid role in having helped market Nicorette gum certainly has the appearance of potentially influencing the reporting of the results of the present research.

If the published abstract was printed with a mistake (which seems unlikely but possible), then the rest of the story is simply that there appears to be a significant financial conflict of interest among one of the study authors that is not disclosed in the paper and which I believe should have been disclosed. Again, this author's history of a past financial relationship with Big Pharma and his apparently paid role in having helped market Nicorette gum certainly has the appearance of potentially influencing the reporting of the results of the present research.

Please note that I am not arguing that the co-author with what I believe is a conflict violated any policy of CHEST. They presumably do not ask authors to disclose "past" conflicts. However, my personal opinion is that these types of "past" conflicts should be disclosed to readers.

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