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The validity of
four often-cited statements about smoking cessation is reviewed and their
misinterpretation is discussed. "Most smokers are interested in
quitting" is true; however, more important is the fact that smokers
try to quit only once every 3.5 years. Thus motivating attempts to
quit and removing barriers to treatment are important. "Most
smokers quit on their own" is often interpreted to mean that
smokers are not nicotine dependent; however, most dependent
alcoholics and drug abusers who quit, do so on their own. This
statement is also often interpreted to mean that most smokers do
not need therapy, but the same was said about clinical depression
in the early 1900s. "Quit rates with treatment are low"; however,
most successful interventions for chronic disorders are the result
of a series of treatments, not just one treatment. "Medication is
effective only when accompanied by psychosocial therapy" is a tenet
of treatment for traditional drug abuse; however, medications such
as over-the-counter nicotine replacement therapies double quit
rates even in the absence of psychosocial therapy.
Public health advocates,
administrators, legislators, etc, have begun to focus on cessation for
smokers. This has occurred, in part, because of the realisation
that there is a lag of 30 to 40 years before the benefits of
prevention are realised, whereas the benefits of cessation occur
within as little as one year.1 This article discusses four commonly
heard statements about smoking cessation and argues that these
statements are either invalid or are often misinterpreted and thus
may impede progress in the treatment of smoking.
"Most smokers are interested in quitting"
Several government publications and
scientific articles have asserted this fact, for example, refs1 2
In the most recent United States survey, 68% of smokers stated that
they were "interested" in quitting.3 This result is
encouraging in that it indicates that many smokers should be
willing to discuss smoking cessation with clinicians and might be
susceptible to our treatments. However, a common misinterpretation
of this result is that smokers are already motivated to quit and we
just need to avail them of treatments. However, if the question is
asked in a more concrete way: "Are you planning on quitting in the
next month?", less than 20% agree.4 If we go by what smokers do,
rather than what they say, we obtain a similar picture. The average
smoker in the United States has smoked for 19 years and made
5.3 quit attempts5; thus on average a smoker tries to
stop once every 3.5 years. In a given year, most smokers
(two-thirds) do nothing at all about their smoking.
In reality we need to focus as much
effort on interventions to prompt cessation attempts as on devising new
treatments. The traditional methods to prompt cessation have
focused on physician or clinician advice2 3 and on
increasing motivation via the media.6 Novel
interventions such as those based on stages of change,7
motivational interviewing,8 and reducing smoking9 are
currently being evaluated as methods to prompt quit attempts.
The complementary action to increase
motivation should be the removal of barriers to quitting, especially barriers
to receiving treatment. The best example of this has been the
switch of nicotine gum and patches to over-the-counter (OTC) status
in the United States. This single event produced an extra
3.8 million quit attempts and an estimated extra 630 000 successful
quitters in the United States in one year.10 It is
particularly important for public health and tobacco control
advocates to take note of this finding because it negates the
common view that pharmacotherapy can never be a cost-effective use
of tobacco control monies. This view is based on the notion that
all pharmacotherapy requires substantial amounts of physician time
which is expensive. However, the cost per quitter with OTC nicotine
replacement therapy (NRT) is quite small.11
Another example of a way to increase
motivation is reducing the cost of treatment. In several studies, providing
free nicotine gum increased quit rates by 2.0-2.4-fold and this
cost appeared to be recovered in reduced healthcare expenditures.12-15
A third example is to make telephone
counselling available. Several studies,16 including some of
supplemental therapies to NRT,17 have found helplines to
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"Most smokers who quit, quit on their own without treatment"
In past surveys, 90-95% of American
former smokers stated that they quit on their own.18 Although the
90-95% figure was true once,18 it is no longer correct.19
A recent analyses examined American pharmaceutical company sales of
NRT and bupropion for the last two quarters of 1998. If one assumes
95% of use of medications is for smoking cessation20 and
that the quit rate with medications is 10%,21 then with
the entry of OTC NRT and bupropion, 37% of all quits in 1998 in the
United States were associated with medication use.19
The statement is also often
misinterpreted to indicate that most smokers are not nicotine dependent; that
those with real dependencies can only quit with treatment. In fact,
although many people believe that most alcoholics who recover do so
via Alcoholics Anonymous, over 75% of successful recoveries from
alcoholism are achieved without treatment.22
Self-recovery is also more common than treatment-induced recovery
among those who are dependent on heroin and cocaine.23
The 90-95% statistic is also often
interpreted as indicating that most smokers do not need therapy. The fallacy
of this logic can be illustrated with a historical analogy. In the
early 1900s, among those who recovered from a true depression, over
90% who did so, did it on their own. Few clinicians or
administrators thought of depression as a disorder at that time.
Most believed it could be cured by simple motivation and, thus, few
treatment resources were made available. Nowadays almost all
clinicians and administrators agree that clinical depression needs
treatment, that there are effective treatments, that making such
treatment readily available improves public health, and that
treatment is worthy of reimbursement. Perhaps administrators',
clinicians', and the public's understanding of nicotine in the
1990s is where the understanding of depression was in the early
Many administrators and clinicians
are unaware of the huge, well accepted dataset that smokers benefit from
treatment.21 Others choose to ignore this dataset, often because
they or someone they know quit on their own. This is especially
tragic given that we currently have six, well proven, very
efficacious therapies21 (behaviour therapy, nicotine gum, patches,
nasal spray, and inhaler, and bupropion). In addition, there is
some evidence that with ongoing social pressure, future smokers
will be those with higher levels of nicotine dependence24
or comorbid psychosocial problems.25 Clinicians believe that many,
if not most, of these smokers will not quit with simple motivation,
no matter how effective the media campaigns. These smokers need
treatment to have a decent chance of quitting. Thus, for example,
cessation monies from American tobacco settlements should go not
only into advertising to motivate cessation, but also into
treatment infrastructure or into the provision of treatment itself.26
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"Quit rates with most therapies are low"
Several articles opined this view.1 2
In most meta-analyses, long-term quit rates from treatment are 20-25%.27
The implicit connotation is that we should expect higher quit
rates. The problem is twofold.
First, nicotine dependence, like all
drug dependencies, is a chronic, relapsing disorder. In other chronic
disorders such as diabetes, any given interventionchanging
the dose of insulin, for examplehas
a small effect on overall outcome; however, the cumulative effect
of interventions, such as 20 years of care by a specialist, can
have a large impact. Thus, these administrators, public health
advocates, and treating clinicians need to accept the notion that
the goal, when treating smoking, is not so much success on any one
given attempt, but is rather the achievement of eventual success in
a given individual in as short a time as possible. For some this
will occur with the first attempt, for others it will not be until
the fourth attempt.
With other chronic relapsing
disorders such as arthritis, a major focus has been on having a single
clinician providing care with multiple regular follow-ups and
seeing the patient through exacerbations and remissions. Current
usual care for smoking is just the opposite. Even in the United
States, many health maintenance organisations provide smoking
cessation therapy as a once-in-a-lifetime option. Systems in which
providers or the media repeatedly prompt quit attempts and provide
therapy probably have the best chance of inducing long-term
The second problem is that a much
more stringent definition of success is usedfor
example, no smoking at all, not even a puff, at weeks
1, 2, 3, 4, 12, 26, and 52 of follow-up among all those who enter
most fields in psychology or medicine. (For drug dependencies, for
example, the criterion is usually reduced drug use at early
follow-up among those who completed treatment.) In fact, if similar
stringent criteria are used, long-term abstinence rates for alcohol
dependence are similar to that for smoking25%
The "low" rates for smoking cessation
are also often compared with "remission rates" of 70% for the treatment of
other behavioural disorders such as depression. The problem again
is one of comparing apples and oranges. The criterion for remission
in depression is relief of acute symptomatology. If a similar
criterion is used for nicotinerelief
medications could also claim a 70% success rate.27 On
the other hand, if the criterion for successful treatment of
depression, among all who were offered medication, was a normal
score on the Beck Depression Inventory for weeks 1-4, 12, 26, and
52 of follow-up, the rate of success for antidepressants would
probably be 25% or less.
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"Medication is effective only when accompanied by a psychosocial
The Food and Drug Administration
label on all smoking cessation products states they are “recommended for use
as part of a comprehensive behavioral smoking cessation program”.
The statement is based on the clinical belief that, for
“traditional” drug dependencies such as alcohol, opioids, and
cocaine, medications alone cannot induce a success. Interestingly,
whether this statement is actually true for alcohol and other
dependencies has been empirically tested in only a handful of
experiments with mixed results.31
In terms of nicotine dependence,
several true experiments and several meta-analytical reviews have clearly
shown that medications double quit rates, independent of adjunctive
psychosocial therapy, and these medications can work even in the
absence of such therapy.32 33 The repeated success of OTC NRT in
controlled trials is further evidence that medications can work
without “talking” therapies.21 Seven studies of OTC patches and gum
have tested NRT without any clinician-patient interaction. All
found that OTC NRT either increased quit rates over placebo or
produced quit rates similar to that found with “real world”
This is not to say that behavioural
and other adjunctive therapies are not effectivethey
do boost quit rates when given alone and when added to medication.32 33
Although use of such therapies is desirable, however, they are not
essential to the success of medication.
Recognising the efficacy of
medications alone is very important as most smokers do not attend talking
therapies34 for the following reasons.35
Unlike alcoholism, the notion that, for some, stopping smoking
requires new learning or insight has not been well accepted by the
Problems exist, not with smokers, but
with the healthcare system, for example: unlike alcohol and drug dependencies,
most healthcare workers do not know where to refer smokers; the
number of chemical dependency rganizati, physicians, psychologists,
social workers, etc in the United States who are competent to
treat nicotine dependence is ridiculously small compared with the
scale of the problem; in most locales, talking therapy for smoking
cessation is available only two or three times per year. (Consider
if this were the case for alcoholism or cocaine addiction!) Unlike
therapy for depression, for most smokers there is no reimbursement
for talking therapies for smoking.36 Despite this, many healthcare
plans insist on attendance at behaviour therapy sessions.
There are two major implications
here. First, requiring attendance at talking therapy sessions to obtain
medication for smoking is without scientific basis and should be
seen as a way to inhibit costs, not to promote health. Second,
rganizatio that behaviour therapy clearly boosts quit rates,
federal programmes, and health maintenance rganizations should make
behaviour therapy as accessible to smokers as therapy for other
scientifically based treatments.
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The area of tobacco control is
probably one of the best examples of science helping out policy. To continue
to move forward, we must examine our beliefs about smoking
cessation and treatment of smoking and change them when the science
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