SRNT Newsletter August/September 2004, Volume 10, Number 3

Volume 10 - No. 3

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SRNT Newsletter

August/September 2004, Volume 10, Number 3

Member Commentary

Commentaries By Lois Biener & John Hughes

Should tobacco control programs encourage smoking cessation without mentioning treatment?


In March 2004, the SRNT list serve hosted an interesting online discussion which was stimulated by one member's concern about the Arizona quit smoking campaign "Go Cold Turkey" ( ). Some SRNT members were concerned that the campaign seemed to be promoting smoking cessation without regard for evidence-based treatments, particularly pharmacotherapy. A number of members felt that a recommendation on how to access pharmacotherapy should always be part of any anti-smoking campaign. They expressed the belief that quit attempts accompanied by pharmacotherapy assured a greater probability of success, and that even though most people who quit smoking do not use these aids, many more people would succeed and would succeed earlier in their life if they did use them. There were concerns that campaigns which fail to mention pharmacotherapy might even be harmful to those smokers most likely to fail without such assistance, possibly resulting in lowered self-efficacy for future quit attempts.

Others, however, saw this type of campaign as a an avenue for potentially motivating smoking cessation by individuals who might either be quite strongly opposed to pharmacotherapy or who might feel that the problem is not of a magnitude that would (yet) warrant pharmacotherapy. In either case, these individuals might not be receptive to anti-smoking campaigns that emphasize medication, and might, as a consequence, dismiss the entire message as not being personally relevant.

Drs. John Hughes and Lois Biener were important contributors to this discussion. They have agreed to summarize their positions for this issue of the SRNT newsletter.

Dr. Hughes' commentary: Despite universal consensus that medications and talking therapies substantially increase the probability of quitting smoking, over 65% of smokers who try to stop smoking do not seek treatment. This is, in part, due to deep-seated beliefs that they "should" be able to quit without assistance, that seeking assistance is a sign of weakness, and that formal treatment is a monetary expenditure that should be avoided. To encourage smoking cessation without mentioning treatment reinforces this belief and denies smokers their best chance of success.

An analogy may be the best way to understand the current and long-term goals of treatments for smoking cessation. In the early 1900s, if people suffered from a major depressive disorder, they were expected to be able to cure themselves. In fact, because effective treatments were available to very few people, over 95% of those who overcame depression did so without professional assistance (sound familiar?). Now, due to the introduction of effective treatments and medical and public education, most Americans realize that many depressed persons are highly unlikely to get better without treatment. Thus, most clinicians would not tell depressed patients that they need to try to get better on their own, without mentioning the possibility of treatment.

I have never understood why so many tobacco control advocates believe that almost all smokers can stop if just sufficiently motivated (one of the few times they and tobacco lawyers agree). Ironically, many of these advocates are the same ones who fervently state that smoking is addicting. Saying smoking is addicting and saying that smokers would not benefit from treatment do not go hand in hand.

In fact, medications and talking therapies for smoking are so well accepted that my human subjects committee says that failure to tell a smoker that these treatments are valid alternatives to entering a treatment study is unethical. So, why is a smoking cessation campaign that fails to mention treatments considered ethical?

Dr. Biener's Commentary: I was among a group of people taking a different perspective. During the listserv discussion, I said, "This clever campaign seems to be an effective way to reach out to the majority of smokers who prefer not to use NRT. In none of the pages that I viewed did I see any attempt to discourage people from use of pharmaceutical aids, and indeed once a person is drawn into the system, they may well encounter advice that steers them to the patch. Although it may cause dismay among the big pharma folks by legitimizing the desire to do it without their products, this campaign speaks to vast numbers of individuals who always believe that cold turkey is the only way."

Among those who agreed with me, one person suggested that the difference of opinion seemed to be an expression of clinical versus public health approaches to cessation, and pointed out that it is not feasible to offer intensive treatments to all smokers at this time, and that even if it were, it isn't clear that most smokers would want them. Others mentioned that the vast majority of people who quit do it without formal help, and wondered whether the continuous pressure to use intensive treatments might not increase the population's perception of the difficulty of quitting and consequently reduce their self-efficacy. Others pointed out that indeed, the Arizona program did offer a variety of helpful methods to quit, including NRT.

Rather than get into a debate about whether the Arizona campaign does or does not expose smokers to the opportunity to use medications if they are interested, let's address the broader question of whether tobacco control programs should always encourage smokers to make use of pharmacotherapy. As you might guess, I would say no. I feel this way for several reasons:

  1. Multiple approaches are needed. Because only a minority of smokers are interested in making a quit attempt in the near future, the message that smokers should quit needs to be expressed continuously, and in a variety of ways so as to reach as much of the smoking population as possible and to cover the multiplicity of motivations for people to attempt cessation.
  2. Most smokers prefer not to use pharmacotherapy. The availability of drugs to aid cessation is widely advertised, yet most people who try to quit and who succeed in quitting decline to use them. Although some argue that this is due to irrational concerns about the safety of nicotine, and that tobacco control programs should educate the public about the products, I feel that is the job of the commercial marketers, not public health agencies.
  3. The effectiveness of NRT in the general population has not been established. In spite of the fact that NRT and other drugs are included in the Public Health Service guidelines, their efficacy has only been demonstrated in carefully controlled clinical trials. Evidence of their effectiveness in general population has been difficult to find. Several population-based surveys have compared the rate of successful cessation among smokers who report having used NRT and those who did not, and find no significant long-term benefit to NRT users. (Thorndike, Biener and Rigotti, 2002; Pierce and Gilpin, 2002). A recent population-based randomized trial compared cessation rates 30 months after treatment among smokers assigned to NRT conditions versus those assigned to manuals only. No significant benefit for the NRT conditions was demonstrated. (Velicer, Fave Prochaska, et al., 2004).

To return, finally, to the "Go Cold Turkey" campaign, it seems to offer a very friendly site for smokers looking for help with quitting. And I'd love to have one of those turkey-shaped stress balls, but I don't think you can get one unless you live in Arizona.

References Cited

Thorndike A, Biener L, Rigotti N. (2002). Effect on smoking cessation of switching nicotine replacement therapy to over-the-counter status. American Journal of Public Health, 92, 437 - 442.

Pierce JP and Gilpin EA. (2002). Impact of over-the-counter sales on effectiveness of pharmaceutical aids for smoking cessation. JAMA, 288, 1260-1264.

Velicer W, Fava J, Prochaska J, Sun X, Cottrill S. (2004). Evaluating NRT and adjuvent therapies in a population-based effectiveness trial. Paper presented at Society of Behavior Medicine Meetings. Baltimore, MD. March.