Summary Points.docx
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Summary Points.docx
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SummaryPoints
∙Researchshowsthattwo-thirdstothree-quartersofex-smokersstopunaided.Incontrast,theincreasingmedicalisationofsmokingcessationimpliesthatcessationneedbepharmacologicallyorprofessionallymediated.
∙Mostpublishedpapersofsmokingcessationinterventionsarestudiesorreviewsofassistedcessation;veryfewdescribethecessationimpactofpoliciesorcampaignsinwhichcessationisnotassistedattheindividuallevel.
∙Manyassistedcessationstudies,butfewifanyunassistedcessationstudies,arefundedbypharmaceuticalcompaniesmanufacturingcessationproducts.
∙Healthauthoritiesshouldemphasisthepositivemessagethatthemostsuccessfulmethodusedbymostex-smokersisunassistedcessation.
Introduction
Aswithproblemdrinking,gambling,andnarcoticsusepopulationstudiesshowconsistentlythatalargemajorityofsmokerswhopermanentlystopsmokingdosowithoutanyformofassistance.In2003,some20yearsaftertheintroductionofcessationpharmacotherapies,smokerstryingtostopunaidedinthepastyearweretwiceasnumerousasthoseusingpharmacotherapiesandonly8.8%ofUSquitattemptersusedabehavioraltreatment.
Moreover,despitethepharmaceuticalindustry'seffortstopromotepharmacologicallymediatedcessationandnumerousclinicaltrialsdemonstratingtheefficacyofpharmacotherapy,themostcommonmethodusedbymostpeoplewhohavesuccessfullystoppedsmokingremainsunassistedcessation(coldturkeyorreducingbeforequitting).In1986,theAmericanCancerSocietyreportedthat:
“Over90%oftheestimated37millionpeoplewhohavestoppedsmokinginthiscountrysincetheSurgeonGeneral'sfirstreportlinkingsmokingtocancerhavedonesounaided.”Today,unassistedcessationcontinuestoleadthenextmostsuccessfulmethod(nicotinereplacementtherapy[NRT])byawidemargin.
Yet,paradoxically,thetobaccocontrolcommunitytreatsthisinformationasifitwassomehowirresponsibleorsubversiveandignoresthepotentialpolicyimplicationsofstudyingself-quitters.Unassistedcessationisseldomemphasizedinadvicetosmokers.Weknowofnocampaignsthathighlightthefactthatmostex-smokersquitunaidedeventhoughhundredsofmillionshavedonejustthat.Reviewstypicallygiveunassistedcessationcursoryattention,framingitasachallengetobeerodedbypersuadingmoresmokerstousepharmacotherapies:
“Unfortunately,mostsmokers…failtouseevidence-basedtreatmentstosupporttheirquitattempts”;“IfthereisamajorfailingintheUKapproach,itisnotthatithasmedicalizedsmoking,butthatithasnotdonesoenough.”Clinicalguidelinesalsoignoreunassistedcessation.Finally,althoughtheUSNationalCenterforHealthStatisticsroutinelyincludedaquestionon“coldturkey”cessationinitssurveysbetween1983and2000,thisquestiondisappearedin2005.
Becauseoftheseprevalentattitudes,smokingcessationisbecomingincreasinglypathologized,adevelopmentthatrisksdistortionofpublicawarenessofhowmostsmokersquittotheobviousbenefitofpharmaceuticalcompanies.Furthermore,thecessationresearchliteratureispreoccupiedwiththedifficultyofstopping.Notably,however,intherareliteraturethathasbotheredtoask,manyex-smokersrecallstoppingaslesstraumaticthananticipated.Forexample,inalargeBritishstudyofex-smokersinthe1980s,beforetheadventofpharmacotherapy,53%oftheex-smokerssaidthatitwas“notatalldifficult”tostop,27%saiditwas“fairlydifficult”,andtheremainderfounditverydifficult.
Werecentlyhypothesizedthatresearchintosmokingcessationfollowswhatwecall“theinverseimpactlawofsmokingcessation.”Thislawpositsthat“thevolumeofresearchandeffortdevotedtoprofessionallyandpharmacologicallymediatedcessationisininverseproportiontothatexamininghowmostex-smokersactuallyquit.Researchoncessationisdominatedbyever-finelytunedaccountsofhowsmokerscanbeencouragedtodoanythingbutgoitalonewhentryingtoquit—exactlyoppositeofhowaverylargemajorityofex-smokerssucceeded.”
InthisPolicyForum,wetestthislawand,becausearecentreviewofCochraneselectedrandomizedcontrolledtrialsofNRT,foundthatwhile51%ofindustry-fundedtrialsreportedsignificantcessationeffects,only22%ofnon-industrytrialsdid,wealsotestthehypothesesthatresearchonpharmaceuticallymediatedcessationisfrequentlyconductedbyresearcherssupportedbypharmaceuticalcompaniesandthatsupportforresearchintounassistedcessationandnon-pharmaceuticalinterventionsislesscommon.
ThroughoutthisPolicyForum,byassistedcessation,wemeananypharmacotherapyoranyindividualorgroupbehavioralorcognitiveintervention.Byunassistedcessation,wemeanapproachesthatinvolvenoneoftheseinterventionsbutinsteadincludeinterventionssuchaschangesintobaccotax,smokingrestrictions,orpublicawarenesscampaignsdesignedtostimulatecessation.Wethenconsiderwhyresearchintohowmostpeoplestopsmokingisbeingneglectedandreflectonthepotentialnegativeconsequencesforpublichealthofrepeatedlymegaphoningthemessagethat“serious”cessationisassistedcessation,amessagethatimpliesthatunassistedcessationislessworthyofresearchattention,publicity,andconsiderationbyquitters.Finally,wesuggesthowthemessagethatsmokersaregettingaboutcessationshouldbeadjustedtohelpmorepeoplequit.
TestingtheInverseImpactLawofSmokingCessation
OnMay12,2009,wesearchedMedlinefor“smokingcessation,”limitingresultstoEnglishlanguageoriginalarticles,meta-analyses,andreviewspublishedin2007and2008.Ofthe885papersreturned,weexcludedthosethatdealtspecificallywiththeeffectsofcessationonbehavioral,cognitiveoraffectivevariables,studyrecruitmentresearch,healtheconomics,andthosepapersthathadadifferentprimaryfocus,suchassmoking-relateddiseases.
Ofthe662papersthatmetourinclusioncriteria,511werestudiesofcessationinterventions.Theother118weremainlystudiesoftheprevalenceofsmokingcessationinwholeorspecialpopulations.Oftheinterventionpapers,467(91.4%)reportedtheeffectsofassistedcessationand44(8.6%)describedtheimpactofunassistedcessation.Someofthosequittingasaconsequenceofunassistedcessationpoliciesorprogramswouldhaveusedassistedmethods,butthesepapersreportedonlyonsmokingstatus,notonhowthosewhoquitdidso.Ofthestudiesdescribingassistedinterventions,247(52.9%)involvedpharmacotherapyand220(47.1%)nondruginterventions.Ofthepapersdescribingcessationtrends,correlates,andpredictorsinpopulations,only13(11%)containedanydataonunassistedcessation.
Wethenrandomlychose30papersthatconsideredassistedcessationinterventions,30thatconsideredunassistedcessationinterventions,and30thatdiscussedtheprevalenceofsmokingcessationtotestthehypothesisthesegroupsofpaperswouldnotdifferintermsofwhetherauthorsand/orstudieshadreceivedsupportfromapharmaceuticalcompanymanufacturingsmokingcessationproducts.Forpapersthatcontainednodeclarationsofcompetinginterestsand/orpharmaceuticalindustryfunding,weemailedthecorrespondingauthorstorequestthisinformation.Wherenoreplieswerereceived,weexaminedtheseauthors'previouspublicationsoncessationfromthepast5yearsforsuchdeclarations.
Ofthe84papersforwhichcompetinginterestinformationwasavailable,12/25(48%)ofpharmacotherapyinterventionstudies,3/29(10.3%)ofnon-pharmacotherapyinterventionstudies,and0/30ofunassistedcessationstudieshadatleastoneauthordeclaringsupportfromacompanymanufacturingcessationproductsand/orresearchfundingfromsuchacompany(p<0.001).Fiveofthesixauthorswhodidnotrespondtorequestsforinformationoncompetinginterestswerepreviouslyinvolvedinstudiesonpharmacologicalinterventionsforcessation.
WhyDoestheResearchConcentrateonAssistedCessation?
Withapproximatelytwo-thirdstothree-quartersofex-smokersstoppingunaided,ourfindingthat91.3%ofrecentinterventionstudiesfocusedonassistedcessationprovidessupportfortheinverseimpactlawofsmokingcessation,althoughfurtherstudiesareneededtoconfirmthatthebiastowardsstudiesonassistedcessationinterventionsthatwediscoveredisalong-standingoneandnotpeculiartotheyearswestudied.Webelievetherearethreemainsynergisticdriversoftheresearchconcentrationonassistedcessationanditscorollary,theneglectofresearchonthenaturalhistoryofunassistedsmokingcessation.Theseare:
thedominanceofinterventionisminhealthscienceresearch;theincreasingmedicalisationandcommodificationofcessation;andthepersistent,erroneousappealofthe“hardening”hypothesis.
TheDominanceofInterventionism
Mosttobaccocontrolresearchisundertakenbyindividualstrainedinpositivistscientifictraditions.Hierarchiesofevidencegiveexperimentalevidencemoreimportancethanobservationalevidence;meta-analysesofrandomizedcontrolledtrialsaregiventhemostweight.Cessationstudiesthatfocusondiscreteproximalvariablessuchasspecificcessationinterventionsprovide“harder”causalevidencethanthosethatfocusondistal,complex,andinteractiveinfluencesthatcoalesceacrossasmoker'slifetimetoendincessation.Specificcessationinterventionsarealsomoreeasilystudiedthanthedynamicsanddeterminantsofcessationinpopulations.Experimentalresearchfocusedonproximalrelationshipsbetweenspecificinterventionsandcessationposesfewerconfoundingproblemsandsitsmoreeasilywithintheprofessionalnormsofscientificgrantassessmentenvironmen
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