Monday, February 19, 2007

New Study Challenges Thinking on Use of NRT During Pregnancy

A new study published in the current issue of the Journal of Health Psychology challenges the conventional wisdom that pregnant smokers should be instructed to use nicotine replacement therapy (NRT) if they are unable or unwilling to quit smoking during pregnancy.

The article highlights the finding that nicotine is probably the agent most responsible for the adverse effects of smoking on the fetus. Nicotine is a neuroteratogen, and "There is now abundant evidence that normal fetal development can be disrupted more specifically by nicotine than by any other component of cigarette smoke. Nicotine, which impacts the brain during critical stages of its intrauterine development in experimental animals, is in the offspring of smoking mothers also the most likely cause of the deficits in learning and memory, and the emotional and behavioral problems seen in childhood and later in life. ... Just published new findings provide experimental evidence that nicotine exposure in pregnancy is responsible for auditory–cognitive deficits in the offspring. ... Prenatal nicotine also primes the adolescent brain for depression, and for nicotine addiction in future years."

Moreover, the article argues that the benefits of NRT use during pregnancy have not been sufficiently demonstrated. Specifically, it is not clear that the benefits of NRT outweigh its risks.

One risk that the article addresses is the possibility that by giving smokers an "easy" alternative, they will not take the issue seriously. If all you need to do is pop a pill and you will lose the urge to smoke, then how compelling is it to describe smoking as being an addictive behavior that requires intense effort to overcome?

Another risk addressed by the article is that because NRT is so unsuccessful during pregnancy, a substantial proportion of pregnant women may continue to both smoke and use NRT, resulting in very high nicotine levels for the developing fetus.

The study concludes: "It is easy not only for the counselors to prescribe NRT, it is also easy for the clients to receive it: they may conveniently assume that this is all that needs to be done, and the urge to smoke may go away in due course. While there is compelling experimental and clinical evidence that nicotine harms the developing fetus in several ways, evidence is lacking that NRT aids smoking cessation in pregnancy. There are pregnant women today who would have quit but are wearing nicotine patches, persuaded by the safety assurances about NRT use. Moreover, new evidence reveals that offering a remedy for a risky behavior inadvertently promotes it by suggesting that the risk is manageable."

The Rest of the Story

I think this is a very important perspective that needs to be considered. Unfortunately, the researchers who are in the greatest positions to influence national policy on treatment of smoking cessation (i.e., those chairing and serving on the panels that are developing the recommendations) are so financially conflicted because of their receipt of pharmaceutical funding that they are in no position to be able to adequately consider such a perspective.

Perhaps now it is easier to see why I have argued that the tobacco control movement is so biased by virtue of its acceptance of money from pharmaceutical companies that we are no position to make rational, balanced, objective policy regarding smoking cessation.

As I pointed out last summer, the World Conference on Tobacco or Health itself was sponsored by Big Pharma, and this precluded the conference from being an objective scientific symposium.

While I have argued previously that these conflicts of interest have harmed tobacco control by denigrating our scientific integrity and objectivity, this article points to the possibility that these financial conflicts of interest are doing more damage than that. Perhaps they are actually harming the public's health because of our promotion of treatments whose costs and risks outweigh their benefits to patients.

Now I don't think there's any doubt that Dr. Fiore needs to be replaced as the chair of the panel which is re-examining the national smoking cessation guidelines put out by the Public Health Service, and that no members should be a part of the panel who have any significant financial conflicts of interest.

You don't appoint a fox to guard a hen house.

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