unassisted cessation
TRANSCRIPT
Simon ChapmanUniversity of Sydney
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Three heretical papers
43,000 downloads
More recently ..
Smith A, Chapman S, Dunlop S. What do we know about unassisted smoking cessation in Australia? A systematic review 2005-2012. Tobacco Control 2013; doi:10.1136/tobaccocontrol-2013-051019
Smith A, Chapman S. Quitting unassisted: the 50 year neglect of a major health phenomenon. JAMA 2014;311(2):137-138. doi:10.1001/jama.2013.282618.
Smith A, Carter SM, Chapman S, Dunlop S, Freeman B. Why do smokers try to quit without medication or counseling? A qualitative study with ex-smokers. BMJ Open 2015; 5:e007301 doi:10.1136/bmjopen-2014-007301
Smith A, Chapman S, Carter SM, Dunlop S, Freeman B. What are the views and experiences of smokers who quit smoking on their own? A systematic review of the qualitative evidence. PLoS One May 26, 2015 DOI: 10.1371/journal.pone.0127144
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Inverse Impact Law of Smoking Cessation
“the volume of research and effort devoted to professionally & pharmacologically mediated cessation is in inverse proportion to that examining how most ex-smokers actually quit. Research on cessation is dominated by ever-finely tuned accounts of how smokers can be encouraged to do anything but go it alone when trying to quit―exactly the opposite of how a very large majority of ex-smokers succeeded.”
Chapman S. Lancet 2009; 373(9665):701-3
“natural recoveries from substance use disorders not only occur but are a common pathway to recovery”
Most with dependencies who quit do so unaided
Problem drinking Narcotics use Gambling Eating disorders Smoking 1986: American Cancer Society : ‘‘Over 90%
of the estimated 37 million people who have stopped smoking in this country since the Surgeon General’s first report linking smoking to cancer have done so unaided.’’
100s of millions worldwide
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WRONG!
“There are some people who can go cold turkey and stop. But there aren’t many of them.”
29,537 adult smokersUnassisted: n= 7714 x 20.6% abstinent = 1589Pharm: n= 3407 x 19.3% abstinent = 6752.35 x more quit unaided in the population
2008
Meta-analysis of 12 NRT RCTs with final follow-up >12m (2408 active & 2384 placebo participants).
RCTs of NRT: 93% fail after 12 months
“the true overall impact of NRT .. is similarly modest and represents success for only about 7% of all those treated in these trials.” (ie 93% fail)
Is there any recommended drug with a 93% failure rate?
How much better is NRT?
Cochrane: >130 studies: NRT 50-70% greater success than placebo
But: trials over-estimate real-world effectstrialists get drugs free of chargeHawthorne effects caused by the research
attention paid to them (average 7.6 per subject), regular reminders and subjects’ desire to please researchers with whom they interact during trials
Exaggerate real-world effects?
Generalisability of findings from clinical trials to “real world”?
66% participants with nicotine dependence excluded from RCTs by at least one criterion (esp. mental health).
Le Strat et al: How generalisable to community samples are clinical trial results for treatment of nicotine dependence? Tob Control 2011;338-43
NRT trials have poor blindness integrity: many on placebo know
12/17 studies that tested for blindness integrity found subjects accurately judged treatment assignment at a rate significantly above chance
Mooney et al: The blind spot in the NRT literature:assessment of the double-blind in clinical trials. Addictive Beh 2004;29:673-84
Pierce et al: Ann Rev Pub Health, 2012
“These results have encouraged governments to recommend strongly that pharmaceutical aids be used in all quit attempts .. To date, there is no evidence that such policies lead to an increase in cessation in the population.”
Pierce et al. Quitlines and nicotine replacement for smoking cessation: do we need to change policy? Ann Rev Pub Health 2012;33:1-16
Real world cessation: unassisted is superior
Displacement of treatment, with no population impact?
Zhu H-S et alQuitting smoking before and after varenicline: a population study based on two representative samples of US smokers.Tob Control doi:10.1136/tobaccocontrol-2015-052332
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Indication bias: more addictive use meds … prognosis worse
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Increased quit attempts, but little increase in 3-month quit rates
Zhu SH et al. Interventions to increase cessation at the population level: how much progress as been made in the last two decades? Tob Control 2012:21: 110-18
1992-2010, USA
Australian impact?• monthly data on
Australian smoking prevalence from 1995-2006, assessing impact of televised anti-smoking advertising, cigarette price, sales of NRT & bupropion, & NRT advertising.
• Neither NRT or bupropion sales nor NRT advertising had any detectable impact on smoking prevalence across the 12-year period
• Anti-smoking advertising and price did
Wakefield et al. Am J Pub Health 2008;98:1443-50
Association for the Treatment of Tobacco Use and Dependence (2012)
NRT “is currently marketed for short-term use as an aid to smoking cessation. Over 100 randomized studies have found NRT increases short term abstinence and in these studies, after NRT has stopped the rate of relapse back to smoking does not differ from that of smokers who quit without treatment. The benefit of treatment is of increasing the initial quit rates not preventing relapse.
In response to Alpert et al study (Tob Control 2012)
“We are not surprised at the results of this study, because evidence is accumulating that smokers who use NRT do not often use it as directed, nor do they use it long enough to stave off relapse, suggesting that we need to educate NRT users better (and the physicians and pharmacists who recommend it) and convince the FDA that 12 weeks is not long enough for NRT to be maximally effective.
Solution? Take it for longer!!
“Most of the studies were performed on people smoking more than 15 cigarettes a day” & “no benefit for using patches beyond 8 weeks”
Few interested in support
3.6% of smokers call quitlineMiller CL, Wakefield M, Roberts L. Uptake and effectiveness of the Australian telephone Quitline
service in the context of a mass media campaign. Tob Control 2003;12 Suppl 2:ii53-8.
1.4% of US smokers call quitlines (2010 data)
UK: in area with highest participation at clinics, 6% attended
Prospects for higher engagement with support very poor
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Compliance very poor
7.2% (active) & 2.8% (placebo) used for >1 month
New Engl J Med 2012;366:808
Irresponsible or subversive information?
Rarely emphasised in information to smokersFew campaigns ever mention itCursory attention in reviewsFramed as a challenge to be forcefully eroded“Unfortunately, most smokers .. fail to use
evidence-based treatments to support their quit attempts”
“If there is a major failing in the UK approach, it is not that it has medicalised smoking, but that it has not done so enough.”
How difficult is quitting?
Much harder than expected: 25 (1.6%)Harder than expected: 87 (5.5%)Total HARDER: 7.1%As expected: 674 (42.8%)Easier than expected: 463 (29.4%)Much easier than expected: 325 (20.6%)Total EASIER: 50%
Source: recently reviewed paper, military sample
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• When citizens have common, ordinary and self-limiting ailments, traits and behaviours constantly redefined as needing treatment … the steady erosion of human agency and self-efficacy as populations lose confidence in their ability to recover or change unhealthy practices is of great concern
• Overly deterministic and disempowering?
Consequences of over-pathologising cessation?
Can we afford both?Maybe in wealthy
nations .. Indonesia: 3 months NRT
costs as much 7 year’s supply of cigarettes
Emphatically no!
Cambodia: $36.80, $20.40, $58.10
What should we tell smokers?
1. unassisted cessation the most common way that most smokers have succeeded in quitting. Unequivocally a positive message - should be openly embraced as front-line, primary “how” message in all clinical encounters & public communication about cessation.
2. Along with motivational “why” messages designed to stimulate cessation attempts, smokers should be repeatedly told cold turkey is method most commonly used by successful ex-smokers;
3. More smokers find it unexpectedly easy or moderately difficult than find it very difficult to quit;
4. “Failures” are a normal part of the natural history of cessation – rehearsals for eventual success.
5. 5. Assistance is a second-line strategy for those who really need help.
