In a book chapter published last week by Future Medicine, I reveal how the public has been massively deceived about the true effectiveness of nicotine replacement therapy (NRT) and identify the need to shift focus toward the use of abrupt, cold turkey strategies for smoking cessation.
(See: Siegel M. Intervention for smoking cessation: from randomized controlled trial to real world. In: Polosa R, Caponnetto P, eds. Advances in Smoking Cessation. London: Future Medicine, 2013: 54-66.)
The chapter begins by citing a recent Cochrane review of the effectiveness of NRT for smoking cessation. It points out that in this "comprehensive" review, the pooled relative risk of smoking cessation associated with pharmacotherapy is given (1.8). The authors conclude that NRT and other drugs are effective for smoking cessation because they double quit rates compared to placebo.
However, what the review does not reveal is the absolute cessation rate achieved with NRT or other drugs. It turns out that the actual success rate - not provided in the article - was only 12.5% for studies that validated quitting biochemically. Thus, as my article states: "the treatment that this review recommends for all patients has a dismal 87.5% failure rate."
But the story does not end there. In real-life, as opposed to clinical trial settings, the quit rate associated with NRT use is only about 10%. I therefore conclude that: "Due to the low success rates for pharmacotherapeutic approaches to smoking cessation, the value of this strategy for smoking cessation is limited."
The article goes on to question a key theoretical assumption in the treatment of smoking dependence: that quitting smoking occurs in stages, according to the Transtheoretical Model (also called the Stages of Change model). I point out a number of studies which document that spontaneous, unplanned quitting is more effective than gradual, planned quit attempts. Some researchers, including Dr. Robert West, have called for the abandonment of the Transtheoretical Model for use in smoking cesation. Following West, I conclude that: "In practice and as supported by a growing body of literature, there is little support for the Transtheoretical Model as a valid description of typical smoking cessation behavior. ... Smoking cessation programs and policies therefore need to lessen their reliance upon the Transtheoretical Model and become open to alternative models which allow for sudden, spontaneous, unplanned behavior that does not require a gradual progression through various stages of change."
I cite the important work of Dr. Simon Chapman who has argued that there is too much of an emphasis in tobacco control on pharmacotherapy, to the almost complete neglect of cold turkey cessation: "Chapman and Mackenzie argue that the majority of successful quitters do so unaided or 'cold turkey,' without the help of pharmacotherapy. Furthermore, they argue that the tobacco control movement has become overly focused on the use of pharmaceutical approaches, neglecting the evidence base which consistently shows that the overwhelming majority of successful quitters have done so cold turkey."
The article also questions the assumption that smoking addiction is solely addiction to nicotine, arguing that the physical, behavioral, psychological, and social aspects of smoking contribute heavily to its addictiveness. This explains why NRT and other forms of pharmacotherapy are so ineffective and why electronic cigarettes represent such a promising approach: "They address not only the pharmacological, but also the physical and even the social aspects of smoking addiction. Placing a nicotine patch does nothing to simulate smoking behavior and there is no social aspect to the behavior. In contrast, electronic cigarettes closely mimic cigarette smoking and they can be used with other people in social settings. Future approaches to smoking cessation must treat smoking addiction more holistically, recognizing that it entails far more than merely a dependence on nicotine."
There are two major recommendations of my article:
1. "Rather than relying on the Transtheoretical Model and focusing on pharmacotherapy or counseling, the basis for an effective smoking cessation program should be an aggressive, hard-hitting, high exposure, anti-smoking media campaign that jolts smokers into quitting, regardless of their previous stage of readiness to quit."
2. "Instead of focusing solely on nicotine replacement, nicotine vaccines, or pharmacologic agents that bind to nicotine receptors, smoking cessation treatment approaches must address the behavioral aspects of smoking addiction in addition to its pharmacological component. The prototype for such a strategy is the electronic cigarette... ."
The Rest of the Story
I sincerely hope that this chapter will help to facilitate a paradigm shift in the tobacco control movement in terms of our strategies to promote smoking cessation.