tag:theconversation.com,2011:/fr/topics/nicotine-replacement-therapy-10769/articlesNicotine replacement therapy – The Conversation2021-01-04T14:50:18Ztag:theconversation.com,2011:article/1517332021-01-04T14:50:18Z2021-01-04T14:50:18ZEight ways to quit smoking in 2021 – what the science says<figure><img src="https://images.theconversation.com/files/376972/original/file-20210104-13-1ot6y52.jpg?ixlib=rb-1.1.0&rect=0%2C25%2C5607%2C3707&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smoking-treatment-man-174166523">Image Point Fr/Shutterstock</a></span></figcaption></figure><p>Lots of people are greeting the new year with plans to quit smoking. The good news is, there is more evidence than ever on the best ways to boost your chances of success. Below we cover the different methods that science suggests are worth a shot. </p>
<p>1. <strong>Behavioural counselling</strong>. The science shows that support for quitting smoking makes you more likely to quit and stay quit than going it alone. Counselling on how to stop smoking is widely available from healthcare professionals and stop-smoking advisers. High-quality evidence from <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013229.pub2/full">over 300 studies in over 250,000 people</a> shows that receiving stop-smoking counselling increases long-term quit rates. </p>
<p>2. <strong>Remote support</strong>. There are many reasons – particularly this year – why you might not be able to see someone face to face for behavioural support. The good news is that <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013229.pub2/full">studies haven’t found any clear difference</a> between the effects of support delivered face to face versus remotely – for example, counselling delivered by telephone or video calls. There is also <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006611.pub5/full">growing evidence</a> that stop-smoking support delivered via text messages can boost quit rates.</p>
<p>3. <strong>Monetary rewards for quitting</strong>. There is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013229.pub2/full">new high-quality evidence</a> that programmes that reward people for successfully quitting smoking increase long-term success. These rewards can include money or vouchers for goods or services. These programmes can be offered by workplaces and in some areas of the world are also available via local governments. They offer the benefit of an <a href="https://theconversation.com/helping-smokers-quit-financial-incentives-work-118488">immediate positive outcome</a> of stopping smoking, as many people find it difficult to think about the longer-term health benefits of quitting.</p>
<p>4. <strong>Nicotine replacement therapy</strong>, known as NRT, has been used safely to help people quit smoking for decades. It can be prescribed by healthcare professionals, but in many countries is available to buy without a prescription from grocery stores and pharmacies. <a href="https://theconversation.com/nicotine-replacement-when-quitting-cigarettes-consider-using-more-nicotine-not-less-115008">Evidence shows</a> that using two forms of NRT rather than one increases your chances of quitting – in particular, using a patch and another form such as gum, sprays or lozenges.</p>
<p>5. <strong>Varenicline</strong>, <a href="https://patient.info/healthy-living/quit-smoking-cessation/varenicline-champix">commonly known as Champix or Chantix</a>, is a medicine for stopping smoking that works by reducing the pleasure people experience from smoking. It also eases withdrawal symptoms when people quit. <a href="http://dx.doi.org/10.1002/14651858.CD006103.pub7">Studies show</a> that varenicline approximately doubles the chances of successful long-term quitting. Varenicline is available on prescription from healthcare providers.</p>
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<img alt="A box of Champix tablets." src="https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Champix reduces the pleasure people experience from smoking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/st-albans-england-10-january-2020-1611713578">Thomas Holt/Shutterstock</a></span>
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<p>6. <strong>Electronic cigarettes</strong> (or e-cigarettes). A <a href="http://dx.doi.org/10.1002/14651858.CD010216.pub4">recent review</a> covering 50 studies and over 12,000 participants found that nicotine e-cigarettes probably do help people to stop smoking for at least six months, and probably work better than NRT and nicotine‑free e-cigarettes. The review didn’t find an association with serious harms. However, <a href="https://theconversation.com/new-evidence-shows-e-cigarettes-can-help-people-quit-smoking-146418">we still need more</a>, reliable evidence to be confident about the effects of e-cigarettes. The good news is, more evidence is <a href="https://podcasts.ox.ac.uk/series/lets-talk-e-cigarettes">on its way</a>.</p>
<p>7. <strong>Combining medication and behavioural support</strong>. <a href="http://dx.doi.org/10.1002/14651858.CD009670.pub4">Studies show</a> that using both behavioural support, such as counselling, and a medicine, such as nicotine replacement therapy, increases quit rates more than using either alone. So for your best shot, try a combination of some of the methods above.</p>
<p>8. <strong>Cut down on how much you smoke</strong>. If you feel like you can’t quit, then try reducing your smoking. <a href="https://academic.oup.com/ntr/article-abstract/8/6/739/1086705">Evidence shows</a> that if you reduce how much you smoke, you are more likely to successfully quit in the long term. When you’re ready to try quitting completely, consider using one or more of the methods listed above.</p>
<h2>A few things to remember</h2>
<p>First, try not to worry about becoming addicted to stop-smoking medication. Most people can stop these medications without problems (if you end up using NRT long-term, remember that the harm from cigarettes <a href="https://theconversation.com/nicotine-replacement-when-quitting-cigarettes-consider-using-more-nicotine-not-less-115008">comes from the tar and not the nicotine</a>). Second, if you have a slip, don’t give up. <a href="https://www.webmd.com/smoking-cessation/features/smoking-relapse#1">This happens to many people</a>, and you should continue your quit attempt. </p>
<p>Finally, don’t be discouraged if you have tried to quit smoking before and it didn’t stick. Lots of people who have tried unsuccessfully to stop smoking eventually manage to quit. It can take a <a href="https://www.nhs.uk/live-well/quit-smoking/what-to-do-if-you-start-smoking-again/">few times to try</a> to stop smoking for good, and there are more ways than ever to help you quit.</p><img src="https://counter.theconversation.com/content/151733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Hartmann-Boyce receives funding from the National Institute for Health Research and Cancer Research UK for research to support quitting smoking. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR or other organisations from which the authors receive research funding. </span></em></p><p class="fine-print"><em><span>Nicola Lindson receives funding from the National Institute for Health Research and Cancer Research UK for research to support quitting smoking. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR or other organisations from which the authors receive research funding.</span></em></p>Experts at Oxford University’s Centre for Evidence Based Medicine review the latest evidence on how to quit smoking.Jamie Hartmann-Boyce, Senior Research Fellow, Departmental Lecturer and Co-Director of Evidence-Based Healthcare DPhil programme, Centre for Evidence-Based Medicine, University of OxfordNicola Lindson, University Research Lecturer, Nuffield Department of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1389052020-06-02T13:51:12Z2020-06-02T13:51:12ZNicotine therapy for coronavirus: the evidence is weak and contradictory<figure><img src="https://images.theconversation.com/files/338883/original/file-20200601-95049-1v30ztp.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5599%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nicotine patch.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smoking-treatment-elderly-person-174163421">Image Point Fr/Shutterstock</a></span></figcaption></figure><p>France recently put <a href="https://www.independent.co.uk/news/world/europe/coronavirus-france-nicotine-patch-gum-research-covid-19-a9484696.html">limits on the purchase nicotine-replacement products</a>, stopping online sales and restricting buyers to a one-month supply of gums, patches and inhalers bought at pharmacies. The limits have nothing to do with the products’ usefulness or safety – these are well established. They have been put in place to stop people stockpiling them following news that nicotine may play a role in combating COVID-19. </p>
<p>There are a <a href="https://www.cebm.net/covid-19/nicotine-replacement-therapy/">number of reasons</a> nicotine is beginning to be explored in this context, but as with everything about the new coronavirus, much remains unknown.</p>
<p>At the outset of the pandemic, <a href="http://www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html">smoking was identified as a risk factor</a> for COVID-19, with the expectation that the same pattern would be seen <a href="https://www.cebm.net/covid-19/smoking-in-acute-respiratory-infections/">as with other respiratory illnesses</a>, namely, that smoking would increase the chance of getting infected and of having worse outcomes once infected. But <a href="https://www.qeios.com/read/UJR2AW.3">some studies</a> have suggested that people who smoke may be at less risk from COVID-19. </p>
<p>So far, no one is sure if this is true. Different studies find conflicting patterns. And in those that find less COVID-19 infection in people who smoke, it is unclear if this is because of a genuine effect or because of issues with analyses or reporting. </p>
<p>We need better quality studies to investigate whether people who smoke are less likely to contract COVID-19. Some of these are underway, but the search for COVID-19 medications is urgent. While we wait for more definitive results, scientists are pressing ahead, following all possible leads in the hunt for a treatment. </p>
<h2>Uniquely deadly</h2>
<p>Tobacco cigarettes are uniquely deadly, killing <a href="https://www2.hse.ie/wellbeing/quit-smoking/reasons-to-quit-smoking/smoking-facts-and-figures.html">one in two</a> regular users. This means it is much more likely that a person who smokes will die from smoking than from COVID-19. </p>
<p>Even if smoking proves protective against COVID-19, no one would ever suggest starting smoking or continuing to smoke to reduce risk. But if something in cigarettes could be protecting people who smoke against COVID-19, there would be a reason to explore this further to see if the useful component could be delivered more safely. The most talked-about candidate so far is nicotine.</p>
<p><a href="https://theconversation.com/nicotine-replacement-when-quitting-cigarettes-consider-using-more-nicotine-not-less-115008">Nicotine</a> is what makes cigarettes addictive, but it doesn’t directly cause the many diseases that affect people who smoke and those around them. </p>
<p>Nicotine has a bad name, which is warranted when considering that more than <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">8 million people die</a> because of tobacco addiction each year. Yet this bad name is not warranted when it comes to nicotine replacement therapy, which delivers nicotine without all of the other harmful components of cigarette smoke. </p>
<p><a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000146.pub5/full">More than a hundred randomised controlled trials</a> have tested nicotine replacement therapy as a way to help people quit smoking, and there is strong evidence that it is safe when used as intended. In fact, the World Health Organization considers nicotine replacement therapy an <a href="https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU-2019.06-eng.pdf?ua=1">essential medicine</a>.</p>
<p>Nicotine has been shown to be <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004722/full">protective</a> in a handful of other diseases, and laboratory studies suggest it may play a part in regulating an enzyme called <a href="https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa077/5834599">ACE2</a>, which is thought to be involved in COVID-19. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192087/">cell receptors</a> that nicotine binds to are ones that SARS-CoV-2 is also thought to affect. Some scientists speculate these links mean <a href="https://erj.ersjournals.com/content/erj/early/2020/04/20/13993003.01116-2020.full.pdf">nicotine would lead to worse COVID-19 outcomes</a>. <a href="https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa077/5834599">Others speculate the opposite</a>. Until tests are done in humans, it’s impossible to know for sure.</p>
<p>Early studies in <a href="http://theguardian.com/world/2020/may/17/plan-study-nicotine-patches-potential-coronavirus-treatment-covid-19">Wales</a> and <a href="https://theconversation.com/does-nicotine-protect-us-against-coronavirus-137488">France</a> are testing nicotine replacement therapy as a potential treatment for COVID-19, and more trials may soon be underway. </p>
<p>It has also been suggested that studies <a href="https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa077/5834599">currently testing nicotine replacement therapy for other conditions</a>, such as a US study looking at nicotine replacement for reducing cognitive impairment, could look at COVID-19 outcomes as well. </p>
<p>If <a href="https://www.cebm.net/covid-19/nicotine-replacement-therapy/">the evidence</a> begins to suggest that nicotine replacement therapy does improve COVID-19 outcomes, there would be a reason to rejoice. We need treatments urgently and nicotine replacement therapy is considered safe, is widely available, and is relatively cheap as it’s not protected by patent. But we are unlikely to know whether nicotine replacement has a role in COVID-19 any time soon. </p>
<p>In the meantime, there is no value in people purchasing nicotine replacement to help protect themselves against COVID-19. Such a move could cause harm by reducing the availability of nicotine replacement therapy for people who wish to quit smoking. For now, nicotine supplies must be preserved for the people who need them.</p><img src="https://counter.theconversation.com/content/138905/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Hartmann-Boyce receives funding from the UK National Institute for Health Research (NIHR), British Heart Foundation (BHF), and Cancer Research UK (CRUK) to do research into smoking cessation and weight management. </span></em></p><p class="fine-print"><em><span>Nicola Lindson receives funding from the UK National Institute for Health Research (NIHR) and Cancer Research UK (CRUK) to do research into smoking cessation. </span></em></p>Eight million people die from smoking each year. Let’s not stockpile the therapy that can help them quit.Jamie Hartmann-Boyce, Departmental Lecturer and Co-Director of Evidence-Based Healthcare DPhil programme, Centre for Evidence-Based Medicine, University of OxfordNicola Lindson, Senior Researcher, Nuffield Department of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1198312019-07-04T12:24:15Z2019-07-04T12:24:15ZE-cigarettes: why I’m optimistic they will stub smoking out for good<figure><img src="https://images.theconversation.com/files/282659/original/file-20190704-51262-rrign9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vape-cigarettes-585182902?src=0MkwCLbW4CEwEX3hxNGtMw-3-20&studio=1">Shutterstock/Lumen Photos</a></span></figcaption></figure><p>There are over a billion smokers across the world – a habit which causes more than <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">7m deaths per year</a>. We have known that <a href="https://tobaccocontrol.bmj.com/content/21/2/87">smoking kills for decades</a>, but this simple fact has not been enough to persuade every smoker to quit. </p>
<p>Even more surprising is that the vast amount of evidence about the risks of smoking hasn’t been enough to put people off starting to smoke in the first place. If knowing smoking kills doesn’t stop people from taking up the habit, what will? </p>
<p>I believe e-cigarettes provide real hope. Available since 2007, these devices often contain nicotine, the addictive substance in cigarettes, but without <a href="https://tobaccocontrol.bmj.com/content/23/2/133">many of the harmful toxicants</a>. Consequently, they are proving to be a seriously disruptive technology which is striking fear into the traditional tobacco industry.</p>
<p>Using <a href="https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update">less harmful</a> ways of delivering nicotine to help people quit smoking is a tried and tested method for quitting smoking. Products like nicotine patches, gums and lozenges have been used <a href="https://tobaccocontrol.bmj.com/content/9/suppl_2/ii60#ref-1">since the 1980s</a> with some success. </p>
<p>E-cigarettes differ from these other products by providing a more similar feel to smoking. Users have to inhale a vapour which provides a throat “hit” similar to smoking. They also have to use the familiar motion of putting the product to their mouth, as they would with a cigarette. </p>
<p>Importantly, these products can provide <a href="https://truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts-stats-and-regulations">similar amounts of nicotine</a> to cigarettes, meaning they hold great potential for helping people to quit smoking.</p>
<h2>Do they actually help people quit smoking?</h2>
<p>E-cigarettes were originally designed to help people quit smoking, but until recently there has been little evidence to show that they work in this regard. This year, a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1808779">study was published</a> which explored how effective e-cigarettes are at helping people to quit smoking. </p>
<p>Participants in the study were assigned to one of two groups in which they either used nicotine replacement products of their choice or e-cigarettes. The findings not only showed that e-cigarettes were effective in helping people quit, but that e-cigarettes were more effective than nicotine replacement therapies. Nearly twice as many people in the study were still smoke free one year after quitting if they had used an e-cigarette compared to using nicotine replacement therapies. </p>
<p>Similarly in my own research, I have found that young people who use e-cigarettes to help them quit smoking are more likely to continue using them than continuing to smoke. Using e-cigarettes to quit smoking was the second most common reason the young people gave for why they had used an e-cigarette. </p>
<p>The most common reason was that they were curious. I think this says a lot about the popularity of the products. People are curious because there are so many users around, making smokers wonder whether e-cigarettes could help them too.</p>
<p>Indeed, e-cigarettes have generally proved to be extremely popular, with an estimated <a href="http://ash.org.uk/media-and-news/press-releases-media-and-news/large-national-survey-finds-2-9-million-people-now-vape-in-britain-for-the-first-time-over-half-no-longer-smoke/">2.9m users in the UK</a>, and around <a href="https://uk.reuters.com/article/us-health-ecigs-us-adults/almost-one-in-20-u-s-adults-now-use-e-cigarettes-idUKKCN1LC2DN">10.8m in the US</a>. Since they were introduced, the use of nicotine patches, gums and lozenges has <a href="http://www.smokinginengland.info/latest-statistics/">significantly decreased</a>. </p>
<p>This combination of effectiveness and popularity could spell the end for cigarettes by tempting more smokers to use e-cigarettes and quit smoking. There are still some users who haven’t tried them though, and this could be due to <a href="http://ash.org.uk/wp-content/uploads/2017/05/ASH-Adult-e-cig-factsheet-2018-corrected.pdf">misconceptions</a> that e-cigarettes are more harmful than cigarettes for users. </p>
<p>By dispelling these misconceptions, we could see an even bigger increase in the popularity of e-cigarettes and consequently a reduction in the amount of people smoking.</p>
<h2>An industry up in smoke?</h2>
<p>Even the tobacco industry seems to feel threatened by e-cigarettes, effectively responding to their popularity by trying to jump on the bandwagon. They have been developing their <a href="https://www.bat.com/ecigarettes">own rival products</a>, and buying shares in popular e-cigarette brands as a reaction to losing so much of their traditional customer base. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/282667/original/file-20190704-51288-1xiy4kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Over and stubbed out?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cigarette-stub-quitting-smoking-180744572?src=rntt7zOHxYbWkzjvnFpDRA-1-19&studio=1">Shutterstock/phildaint</a></span>
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</figure>
<p>Some big tobacco companies have even made this part of their sustainability plan. To me, this reiterates that the industry cannot be sustained by the sale of tobacco cigarettes. Less harmful devices are eventually likely to eradicate sales.</p>
<p>I see great potential in e-cigarettes in the fight against tobacco. The evidence suggests that they are less harmful than cigarettes, more effective at helping people quit smoking than traditional nicotine replacement options, and popular. </p>
<p>All of this has the tobacco industry scared enough to invest in e-cigarettes because they fear for the sustainability of their traditional market. This makes me confident that e-cigarettes will be the disruptive technology which sees smoking stubbed out for good.</p><img src="https://counter.theconversation.com/content/119831/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jasmine Khouja does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>They’re effective – and popular.Jasmine Khouja, PhD Candidate, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1150082019-04-18T13:11:40Z2019-04-18T13:11:40ZNicotine replacement: when quitting cigarettes, consider using more nicotine, not less<figure><img src="https://images.theconversation.com/files/269778/original/file-20190417-139084-cpbfvo.jpg?ixlib=rb-1.1.0&rect=80%2C17%2C678%2C613&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?u=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTU1NTUyNjcwMiwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfNTUzMzczMzA4IiwiayI6InBob3RvLzU1MzM3MzMwOC9tZWRpdW0uanBnIiwibSI6MSwiZCI6InNodXR0ZXJzdG9jay1tZWRpYSJ9LCJJK2RFZXFZdngxZWFWMkZqZktzaHhoZGk3Y2MiXQ%2Fshutterstock_553373308.jpg&pi=33421636&m=553373308&src=oTsZLPeUAQT4VyaU3RmzHg-1-29">Shutterstock</a></span></figcaption></figure><p>When delivered through cigarettes, nicotine is considered to be one of the <a href="https://theconversation.com/the-five-most-addictive-substances-on-earth-and-what-they-do-to-your-brain-54862">most addictive substances on Earth</a>, so it may seem odd to suggest that people should use more, rather than less, to quit smoking. A <a href="https://doi.org/10.1002/14651858.CD013308">recent review of the research</a>, however, has found just that.</p>
<p>Nicotine replacement therapy, known as NRT, has been used to help people <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000146.pub5/full">safely quit smoking</a> for more than 20 years. It can be prescribed by a doctor but, in many countries, is also available to buy from grocery stores and pharmacies. The <a href="https://doi.org/10.1002/14651858.CD013308">Cochrane review</a> (<a href="https://www.cochrane.org/">Cochrane</a> assesses evidence on healthcare interventions and summarises the findings) looked at the best ways to use NRT to quit smoking – and found three ways in which using more nicotine might help:</p>
<ol>
<li><p><strong>Use two forms of NRT rather than one</strong>. NRT is available in a range of forms: skin patches, chewing gum, nasal and oral sprays, inhalators, and lozenges. There is high quality evidence that sticking on a patch while also using another form of NRT, such as gum, increases your chances of quitting.</p></li>
<li><p><strong>Start to use NRT before stopping smoking</strong>. Usually people start using NRT on the day they quit. But starting to use NRT a few weeks before, while they’re still smoking, may help more people to quit successfully. </p></li>
<li><p><strong>Higher doses of NRT may help some people</strong>. Some NRT releases higher levels of nicotine than others. In the studies reviewed, people were more likely to quit if they used 4mg compared to 2mg nicotine gum. The higher dose may be particularly helpful for people who smoke more cigarettes – for example, over 20 a day. Evidence also suggests that using 21mg or 25mg patches might increase the chance of quitting compared to using 14mg or 15mg patches. </p></li>
</ol>
<h2>But why?</h2>
<p>There are several good reasons why using nicotine in this way can be the solution, rather than the problem. </p>
<p>First, it can make cigarettes less enjoyable. Smokers find smoking pleasurable because <a href="https://www.nhs.uk/common-health-questions/lifestyle/why-is-smoking-addictive/">nicotine from cigarettes makes the brain release dopamine</a> – a “happy” hormone. The brain gets used to this, so when a smoker hasn’t smoked for a while, they start to experience <a href="https://smokefree.gov/challenges-when-quitting/withdrawal/understanding-withdrawal">unpleasant symptoms</a>, such as cravings, sleep problems and mood changes.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-five-most-addictive-substances-on-earth-and-what-they-do-to-your-brain-54862">The five most addictive substances on Earth – and what they do to your brain</a>
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</p>
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<p>NRT provides the brain with an alternative source of nicotine, which eases these symptoms. When <a href="https://www.bmj.com/content/361/bmj.k2164">NRT is used before quitting</a>, brain receptors are already filled with nicotine when a cigarette is smoked. Therefore, the smoker doesn’t get the usual burst of pleasure from smoking, helping to break the association between smoking and feeling good.</p>
<p>Second, NRT replaces a harmful way of delivering nicotine with a safe alternative. Some people may worry that taking more nicotine will cause side effects. Fortunately, <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000146.pub5/full">NRT is considered safe</a>, and this review didn’t find any evidence of overdosing on NRT if used as directed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/269777/original/file-20190417-139110-q50mkj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Using nicotine gum with another form of NRT may be helpful.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?u=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTU1NTUyNjUyOCwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMzczODAwNzYiLCJrIjoicGhvdG8vMzczODAwNzYvbWVkaXVtLmpwZyIsIm0iOjEsImQiOiJzaHV0dGVyc3RvY2stbWVkaWEifSwiWGdtTmNPK3o4RnZ1VHhLWUREdXd2RVlKbzhrIl0%2Fshutterstock_37380076.jpg&pi=33421636&m=37380076&src=jQAnnrM_swWuayq9mUcPJw-1-39">Shutterstock</a></span>
</figcaption>
</figure>
<p>Smoking is dangerous because of the <a href="https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/whats-in-a-cigarette-0">many harmful chemicals</a> present in cigarette smoke, including arsenic and formaldehyde. None of these are present in NRT.</p>
<p>Finally, NRT is not as addictive as smoking. Some people are concerned about becoming addicted to NRT. But the way cigarettes deliver nicotine makes them far more addictive than NRT. Cigarettes deliver nicotine to the brain extremely quickly, and do so alongside other chemicals, which increase the force with which nicotine affects the brain. Because nicotine from NRT is delivered to the brain much more slowly, and without those extra chemicals, smokers do not experience the same quick hit of pleasure when they use NRT. This makes NRT less addictive.</p>
<p>Quitting smoking is hard, but important – even people who’ve smoked for many years can improve their health by quitting. The problem with nicotine is that it gets people addicted to smoking, but cigarettes – not nicotine – are the killer.</p>
<p>In 1976, eminent professor, Mike Russell, wrote “<a href="https://www.bmj.com/content/1/6023/1430">People smoke for nicotine but they die from the tar</a>”. This is as true today as ever, and evidence shows that more nicotine can be part of the answer.</p><img src="https://counter.theconversation.com/content/115008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicola Lindson has received funding from the UK's National Institute for Health Research to carry out research into nicotine preloading. The study completed in 2016.</span></em></p><p class="fine-print"><em><span>Jamie Hartmann-Boyce does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent Cochrane review came to a surprising conclusion.Jamie Hartmann-Boyce, Senior Researcher, Health Behaviours, University of OxfordNicola Lindson, Postdoctoral Research Fellow, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1107392019-01-30T22:04:15Z2019-01-30T22:04:15ZE-cigarettes nearly twice as effective as other nicotine replacement therapies at helping smokers quit<figure><img src="https://images.theconversation.com/files/256129/original/file-20190129-108367-1fw4icm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/276067694?src=Dcq5qo643Bdc9p1TkvvsWQ-1-1&size=medium_jpg">Oleggg/Shutterstock</a></span></figcaption></figure><p>Many smokers successfully quit by switching to e-cigarettes (vaping), but doctors can’t recommend this treatment without good evidence from clinical trials. They now have this evidence. Our <a href="https://doi.org/10.1056/NEJMoa1808779">latest study</a> confirms that e-cigarettes are indeed an effective way to help smokers quit. </p>
<p>In the trial, published in the New England Journal of Medicine, almost 900 smokers seeking to quit were randomly assigned to one of two groups. One group was given nicotine replacement therapy (NRT) – mostly combinations of nicotine patches with a shorter-acting medication, such as nicotine chewing gum, inhaler or mouth spray. The other group was given a refillable e-cigarette, with one or two bottles of e-liquid, and taught how to use the device. They were then encouraged to buy more supplies of their choice, with nicotine strengths and flavours that they liked. Both groups also received weekly face-to-face support over at least the first four weeks of the study. </p>
<p>When heavy smokers try to quit, they often feel miserable for a while, struggling with urges to smoke, irritability and low mood. The group using e-cigarettes experienced fewer of these symptoms than the group using NRT. They also found e-cigarettes more helpful and more satisfying, although they didn’t find e-cigarettes or NRT as satisfying as cigarettes.</p>
<p>Vapers maintained their early advantage over the course of the study. At the end of the year, almost twice as many people in the e-cigarettes group had been abstinent throughout the year compared with the NRT group (18% vs 10%). </p>
<h2>Strong difference</h2>
<p>Early in the study, both groups used their treatments nearly every day. Over time, though, a strong difference emerged. Some 40% of smokers in the e-cigarette group were still vaping at one year while only 4% in the NRT group were still using their nicotine replacement product. Among those not smoking at one year, the proportion using e-cigarettes was 80%, and using NRT was 9%.</p>
<p>Among smokers who didn’t manage to quit, there were some in both study groups who reduced their smoke intake by at least 50%, but there were significantly more of them in the e-cigarette group (13% vs 7%). </p>
<p>Ongoing vaping among the long-term abstainers, however, could be seen as a bad thing if using e-cigarettes for one year leads to vaping over many more years, and if this causes health problems. Although the risks of long-term vaping on health are estimated to be less than 5% of the risks of smoking (no health risks from vaping <a href="https://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose">were found</a> in one gold-standard study looking at over two years of e-cigarette use), this could still present an avoidable risk. </p>
<p>But the fact that many of the heavy smokers in our study who stopped smoking carried on vaping could be seen as a good thing. Dependent smokers who quit with NRT and continue to use these products in the long-term are known to <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.1360-0443.2001.961217575.x">reduce their risk of relapse</a>, so extended use of e-cigarettes might also reduce the risk of relapse. Also, ongoing vaping protected these heavy smokers from the usual side effects of quitting, such as feeling irritable and gaining weight. And an issue that is rarely discussed is that some smokers actually enjoy smoking, and vaping may help them retain this enjoyment.</p>
<p>These ex-smokers are, of course, still continuing to use nicotine through vaping, but this does not have the major negative effects on health that cigarettes have. The health risks of smoking are mainly from combustion chemicals released from burning tobacco. People who use nicotine without combustion, such as <a href="https://tobaccocontrol.bmj.com/content/12/4/349">users of Swedish snus</a> and <a href="https://link.springer.com/article/10.2165%2F00023210-200216100-00001">short- or long-term users of nicotine-replacement products</a>, do not seem to suffer negative health effects, while smoking causes premature death in about <a href="https://www.sciencedirect.com/science/article/pii/S016950029700648X">half of middle-aged smokers</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/256342/original/file-20190130-108370-1fcjbun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The chemicals that help cigarettes burn mostly carcinogenic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1143239804?size=medium_jpg">Catsence/Shutterstock</a></span>
</figcaption>
</figure>
<p>We are continuing to follow the trial participants and will eventually have data on how long the long-term vapers continue to vape for and what effect this has on their health and their relapse rate. In the meantime, doctors can tell smokers that there is good evidence that vaping can help them quit.</p><img src="https://counter.theconversation.com/content/110739/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katie Myers Smith and team received funding for the current study from by the National Institute for Health Research (NIHR).</span></em></p><p class="fine-print"><em><span>Hayden Mc Robbie has received honoraria for speaking at smoking cessation meetings and attending advisory board meetings that have been organised by Pfizer and Johnson & Johnson. He has also received research grants from the National Institute for Health Research (UK) and Cancer Research UK.
</span></em></p><p class="fine-print"><em><span>Peter Hajek receives funding from MRC, NIHR, CRUK, Pfizer, PHE, CTAS</span></em></p>New clinical trial shows vaping is an effective way to quit smoking.Katie Myers Smith, Senior Research Fellow, Research Health Psychologist, Queen Mary University of LondonHayden McRobbie, Professor in Public Health Interventions, Queen Mary University of LondonPeter Hajek, Professor of Clinical Psychology, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/897672018-01-09T04:11:39Z2018-01-09T04:11:39ZDrugs, gums or patches won’t increase your chances of quitting<figure><img src="https://images.theconversation.com/files/201291/original/file-20180109-83547-929l8t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drugs don't give you an edge over quitting cold turkey.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/764075719?src=UJP0t-Ts3CdfLW7xHkFvyQ-1-95&size=huge_jpg">Shutterstock/shanon mungmee</a></span></figcaption></figure><p>Using prescription drugs or over-the-counter products like gums, mints or patches won’t increase your chances of quitting smoking a year later, according to a <a href="https://academic.oup.com/jnci/advance-article/doi/10.1093/jnci/djx240/4768312">new study</a>.</p>
<p>The US researchers followed two groups of people 2002/03 and 2010/11 and found at the end of the 12-month period, those using varenicline (sold in Australia as Champix), bupropion (Zyban), or nicotine-replacement therapy (gums, mints or patches) were no more likely to have quit smoking for 30 days or more than those who didn’t use these drugs.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-champixs-effectiveness-is-questionable-and-safety-record-is-concerning-85259">Weekly Dose: Champix's effectiveness is questionable and safety record is concerning</a>
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<h2>Evidence based smoking cessation?</h2>
<p>We’re told the best way to quit smoking is to use an “evidence-based” method: a strategy supported by high-quality research evidence. And for the last 30 or so years, this has been nicotine-replacement therapy, bupropion (Zyban) and varenicline (Champix), which claim to increase (and <a href="https://www.cincottachemist.com.au/instore_services/my-quit-plan">sometimes double</a>) your chance of success.</p>
<p>In the <a href="https://en.wikipedia.org/wiki/Hierarchy_of_evidence">hierarchy of evidence</a>, the lowest form is anecdote or case studies (“I smoked for 20 years, then an alternative therapist sprinkled magic powder on me, and the next day I stopped smoking!”). These cannot withstand the most elementary critical appraisal, starting with the basic question of how many similar smokers sprinkled with the powder kept smoking and how many who went nowhere it also stopped smoking.</p>
<p>Far higher up the evidence pyramid is the double-blinded, randomised controlled trial (RCTs). In these, both the person taking the treatment and those delivering it are unware of who is taking the active drug and who is taking the comparison placebo or comparison drug. All enrolled in RCTs are randomly allocated to the active or placebo/comparison groups. The numbers of participants are sufficiently large enough to allow for an outcome to be declared statistically significant (or not) above a chance finding.</p>
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Read more:
<a href="https://theconversation.com/randomised-control-trials-what-makes-them-the-gold-standard-in-medical-research-78913">Randomised control trials: what makes them the gold standard in medical research?</a>
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<p>Some have tried to dismiss earlier findings about the poor performance of nicotine-replacement therapy by emphasising “<a href="http://tobaccocontrol.bmj.com/content/14/5/346">indication bias</a>”. In the real world, those who opt to use medications to try to quit are likely to be more intractable smokers, more highly addicted to nicotine, and with histories of failure at quitting unaided. No one should therefore be surprised if they fail more often than those who try to quit on their own.</p>
<p>In this new study, this issue was anticipated and all smokers were assessed by what the study authors called a “propensity to quit” score. This score accounts for factors such as smoking intensity, nicotine dependence, their quitting history, self-efficacy to quit, and whether they lived in a smoke-free home where quitting would likely be more supported.</p>
<p>In the analysis, those who tried to quit with drugs and those who didn’t were matched on this propensity score, so “like with like” could be compared in the analysis. The findings held even when these “propensity” to quit factors were taken into account. </p>
<h2>RCTs are very different to real world use</h2>
<p>Critics have long pointed out that RCTs have many features which make them a pale shadow of how drugs are used in the real world. </p>
<p>RCTs <a href="https://www.ncbi.nlm.nih.gov/pubmed/21212379">often exclude</a> people with mental illness, poor English, and no fixed address. Excluding hard-to-reach and treat participants is likely to produce more flattering results.</p>
<p>In the real world, people are not paid or otherwise incentivised to keep taking the drugs across the full period of the trial, so compliance is almost always far lower.</p>
<p>In the real world, people do not get reminder calls, texts or visits from researchers highly motivated to minimise trial drop-out. There is no “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936999/">Hawthorne effect</a>”: when trial involvement and the attention paid to participants alters the outcomes.</p>
<p>Nicotine-addicted people generally know very quickly if they have been allocated to the placebo arm in NRT trials because their brains feel deprived of nicotine. They invariably experience unpleasant symptoms. Knowing they have been allocated to the placebo <a href="https://www.ncbi.nlm.nih.gov/pubmed/15135549">undermines the integrity of the trial</a> because it is important participants believe the drug might be effective.</p>
<p>Large, real world studies like the one just published, which assess long-term success, not just end-of-treatment or short-term results, are therefore of most importance in assessing effectiveness. These new data ought to cause such rhetoric to cool right down. </p>
<p>As for the evidence on e-cigarettes in quitting, neither the US <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1">Preventive Health Services Task Force</a>, nor the UK’s <a href="https://www.nice.org.uk/guidance/ph45/chapter/1-Recommendations">National Institute for Health and Care Excellence</a> or Australia’s <a href="https://www.nhmrc.gov.au/_files_nhmrc/file/publications/17072_nhmrc_-_electronic_cigarettes-web_final.pdf">National Health and Medical Research Council</a>, have endorsed e-cigarettes as an effective way of quitting smoking.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-quit-smoking-switching-to-e-cigarettes-no-advantage-40499">Want to quit smoking? Switching to e-cigarettes no advantage</a>
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<p>Quitting smoking is the single most important thing anyone can do to reduce the likelihood they will get heart or lung disease, and a whole string of cancers. </p>
<p>It has been in the clear interests of the pharmaceutical and, more recently, the vaping (e-cigarette) industries, to promote the notion that anyone who tries to quit alone is the equivalent of someone with pneumonia refusing antibiotics. Hundreds of millions around the world have quit smoking without using any pharmaceutical intervention.</p>
<p>Before nicotine-replacement therapies became available in the 1980s, <a href="https://jamanetwork.com/journals/jama/article-abstract/1812969?redirect=true">many millions of smokers successfully quit</a> smoking without using any drug or nicotine substitute. The same still happens today: <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000216">most ex-smokers quit by going cold turkey</a>. </p>
<p>The problem is, in recent years, the government has moth-balled the national quit campaign, the megaphone for promoting this very positive message. Commercial interests are now commodifying something millions have always done for themselves.</p><img src="https://counter.theconversation.com/content/89767/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Using prescription drugs or over-the-counter gums, mints or patches won’t increase your chances of quitting smoking a year later, according to new study.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/852592017-11-23T19:13:26Z2017-11-23T19:13:26ZWeekly Dose: Champix’s effectiveness is questionable and safety record is concerning<figure><img src="https://images.theconversation.com/files/195369/original/file-20171120-18533-hmv04h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smoking cessation aid Champix has been linked to suicides. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Champix was developed by drug company Pfizer as a smoking cessation treatment in 1997. Its active ingredient, varenicline, can <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-CMI-06101-3&d=2017103016114622483">block the effects of nicotine</a> and reduce craving. <a href="http://www.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2016-11/files/varenicline-psd-november-2016.pdf">It was approved</a> for use in Australia in 2007.</p>
<p>It’s commonly prescribed in Australia, but there are concerns about potentially serious side effects. In September 2017, the <a href="http://www.abc.net.au/news/2017-09-14/conroners-finds-anti-smoking-drug-champix-contributed-to-suicide/8946320">Queensland coroner found Champix</a> contributed to the death of a 22-year-old man who had died by suicide.</p>
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<h2>How it works</h2>
<p>Receptor proteins in the brain, called the nicotinic acetylcholine receptors, respond to drugs, including nicotine. Inhaling cigarette smoke creates a process that includes nicotine attaching to these receptors, and the release of the chemical dopamine, which affects the reward centre in the brain. </p>
<p>The feeling of pleasure associated with dopamine lasts only a short time. This reinforces craving, frequent use and can lead to addiction. <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-CMI-06101-3&d=2017103016114622483">Champix was developed</a> to relieve cravings associated with withdrawal symptoms by stopping the nicotine from attaching to the receptors. </p>
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Read more:
<a href="https://theconversation.com/chew-on-this-smokers-nicotine-replacement-therapies-rarely-work-4954">Chew on this, smokers: nicotine replacement therapies rarely work</a>
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<h2>What are the side effects?</h2>
<p>There have been <a href="https://www.tga.gov.au/publication-issue/medicines-safety-update-no4-2010">ongoing concerns around the potential side effects</a> of Champix. By May 2010, the Therapeutic Goods Administration (TGA) had received 1,025 reports of suspected adverse reactions. Two-thirds (67%) of these described psychiatric symptoms including depression, agitation, anxiety, altered mood and aggression. There were also 206 suicide-related events such as suicide attempts and thoughts or plans, including 15 suicides. </p>
<p>A <a href="https://www.tga.gov.au/alert/varenicline-champix">December 2015, TGA Safety Update</a> noted serious neuropsychiatric symptoms had occurred in patients being treated with varenicline. The update advised patients and families to contact a health care professional “if changes in behaviour or thinking, agitation or depressed mood that are not typical for the patient are observed, or if the patient develops suicidal ideation or suicidal behaviour”. </p>
<p><a href="https://www.tga.gov.au/alert/varenicline-champix">Possible symptoms listed</a> include “anxiety, agitation, aggression, mood swings, self-harm, thoughts of self-harm, or seeing, hearing or sensing things that are not there”.</p>
<h2>Suicide warnings</h2>
<p>Prior to the <a href="http://www.abc.net.au/news/2017-09-14/conroners-finds-anti-smoking-drug-champix-contributed-to-suicide/8946320">recent Queensland case</a>, the Victorian Coroner’s Court released a similar finding in 2015. Champix was linked to the suicide of a 36-year-old man, and <a href="http://www.coronerscourt.vic.gov.au/home/coroners+written+findings/findings+-+finding+without+inquest+into+the+death+of+benjamin+david+johnston">the court stated</a> the evidence supports the finding that the death was an adverse reaction to the drug varenicline. </p>
<p>The Victorian Institute of Forensic Medicine now tests for Champix use in their routine toxicological analyses to determine if any potential link exists between its use and suicide. <a href="https://www.theguardian.com/business/2017/sep/15/his-death-still-hurts-the-pfizer-anti-smoking-drug-ruled-to-have-contributed-to-suicide">The Queensland Coroner</a> recommended this model be adopted by all states and territories.</p>
<p>Concerns about Champix are not restricted to Australia. In the United States, Pfizer reached out-of-court settlements totalling US$273 million with 2,700 complainants following a 2013 class action that claimed Chantix (the US product name) increased the risk of suicide. In 2014, the US Food and Drug Administration (FDA) applied its highest level “black box” warning that alerted users to serious side effects. </p>
<p>The <a href="https://www.fda.gov/Drugs/DrugSafety/ucm532221.htm">safety warning was downgraded</a> in the FDA’s 2016 Drug Safety Communication update. The update notes, however, the risk of potential side effects on mood, behaviour, or thinking remains, particularly among people receiving treatment for depression, anxiety disorders, or schizophrenia, or have been previously treated for mental illnesses. </p>
<p><a href="https://www.healthnewsreview.org/2017/01/chantix-black-box-warning/">Critics have raised concerns</a> about the FDA’s decision to downgrade, and about the evidence it used in making the decision, which was <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30272-0/abstract">taken from trials funded by Pfizer</a> and GlaxoSmithKline. </p>
<h2>How much it’s used</h2>
<p>TGA data show 1.7 million Champix prescriptions were dispensed in Australia between <a href="https://www.theguardian.com/business/2017/sep/15/his-death-still-hurts-the-pfizer-anti-smoking-drug-ruled-to-have-contributed-to-suicide">2011 and 2016</a>. Patients currently pay A$38.80 for a pack of 56 Champix tablets under the PBS listing. </p>
<p>This volume of prescriptions raises important questions about the effectiveness of Champix in helping smokers to quit. Randomised clinical trials of varenicline-based products return impressive results. A <a href="http://www.cochrane.org/CD006103/TOBACCO_can-nicotine-receptor-partial-agonists-including-cytisine-and-varenicline-help-people-stop-smoking">recent review of trials</a>, for instance, reported a standard dose of the drug more than doubled the chances of quitting compared with placebo. </p>
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Read more:
<a href="https://theconversation.com/despite-help-on-offer-many-smokers-prefer-to-quit-on-their-own-heres-why-41749">Despite help on offer, many smokers prefer to quit on their own – here's why</a>
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<p>But like all drugs to help quit smoking, impressive quit rates returned under optimal trial conditions are not replicated in real life. And many trials that return positive results are <a href="https://academic.oup.com/phe/article-abstract/8/3/319/2362712?redirectedFrom=fulltext#ref-48">funded by the pharmaceutical industry</a>. </p>
<p>The reality of smoking cessation is that <a href="https://campaigns.health.gov.au/smokes/get-ready-quit">most former smokers quit unassisted</a>, without prescription drugs like Champix, or nicotine replacement therapy. Ongoing controversy about the health risks of Champix and its limited effectiveness as a cessation aid raise questions about the government’s continued investment in listing it on the PBS.</p>
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<p><em>Anyone seeking support and information about suicide can contact <a href="https://www.lifeline.org.au/">Lifeline</a> on 131 114, or <a href="http://www.beyondblue.org.au/">beyondblue</a> 1300 22 46 36.</em></p><img src="https://counter.theconversation.com/content/85259/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross MacKenzie receives funding from from the National Institutes of Health. He he has previously worked on research projects funded by the Rockefeller Foundation, and Cancer Council NSW.</span></em></p>This smoking cessation tablet has been linked to suicides, so why is it still publicly subsidised?Ross MacKenzie, Lecturer in Health Studies, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/840582017-10-01T18:41:12Z2017-10-01T18:41:12ZWhy we should pay people to stop smoking<figure><img src="https://images.theconversation.com/files/186315/original/file-20170918-24069-45i34c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Immediate cash incentives have been shown to be more effective in helping people quit, and cost us less in the long-run. </span> <span class="attribution"><a class="source" href="https://unsplash.com/search/photos/smoking?photo=3QWGZnbjWk8">Sajjad Zabihi/Unsplash</a></span></figcaption></figure><p>Despite some of the strictest tobacco control policies in the world, <a href="https://www.aihw.gov.au/reports-statistics/behaviours-risk-factors/smoking/overview">recent data shows</a> the decline in smoking in Australia has stalled.</p>
<p>“First-line” quitting strategies available in Australia such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664870/">nicotine patches</a> offer around a 7% success rate (or 93% failure rate, depending on how you look at it). This will not achieve our 9% smoking target <a href="http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/A06C2FCF439ECDA1CA2574DD0081E40C/$File/discussion-28oct.pdf">by 2020</a>, given that we are at <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mediareleasesbyCatalogue/E6DE72422D16BBB4CA258130001536C2?OpenDocument">about 14%</a> now. </p>
<p>With current approaches and policies adopted in Australia having arguably lost their edge, and with more controversial approaches such as <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/VaporisedNicotine/Report">e-cigarettes</a> caught up in political quicksand, let’s invest in the strategies that do work. </p>
<p>One evidence-based approach that has not received much attention in Australia is using financial incentives. Incentives programs reward quitters for not smoking by giving them a monetary voucher. The quitter’s abstinence is verified using <a href="https://academic.oup.com/ntr/article-lookup/doi/10.1080/14622200210123581">biochemical tests</a> of either their saliva, urine or breath.</p>
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Read more:
<a href="https://theconversation.com/is-it-time-to-stop-subsidising-nicotine-replacement-therapies-36760">Is it time to stop subsidising nicotine replacement therapies?</a>
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<h2>What’s the evidence for financial incentives?</h2>
<p>Financial incentive programs are one of the most <a href="https://www.ncbi.nlm.nih.gov/pubmed/25983287">effective</a> and <a href="https://www.nice.org.uk/guidance/ph10/evidence/economic-analysis-of-interventions-for-smoking-cessation-aimed-at-pregnant-women-369843373">cost effective</a> strategies for getting people to quit. They are considered the most effective strategy for <a href="https://www.ncbi.nlm.nih.gov/pubmed/24154953">pregnant smokers</a>. They are also cost effective, with the calculated net benefit (after taking into account of the incentives used) being around A$4,300 per smoker, per attempt to quit. There have been a number of studies showing their benefits.</p>
<p>Using a multinational company as a test site, <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa0806819">a team of US researchers</a> found people who were offered US$750 (A$938) to quit smoking were three times more successful than those who were not given any incentives. Even six months after the vouchers had stopped, previously incentivised quitters were 2.6 (21.9% vs 11.8%) times more likely to still be smoke-free compared to non-incentivised quitters.</p>
<p><a href="http://www.bmj.com/content/350/bmj.h134.long">A team of UK</a> researchers randomised over 300 pregnant women to receive up to £400 (A$661) worth of shopping vouchers if they quit during the pregnancy. Again, women in the incentives group were 2.6 (22.5% vs 8.6%) times more likely to have stopped smoking at the end of pregnancy, compared to the women who had received counselling and nicotine replacement therapy.</p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0735109716334477">A Swiss program</a>, offering low-income smokers up to US$1,650 (A$2,063) worth of quit-contingent vouchers staggered over six months, found smokers were 1.6 (18.2% vs 11.4%) times more likely to be smoke-free at 18 months compared to non-incentivised smokers.</p>
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Read more:
<a href="https://theconversation.com/gp-guide-is-wrong-patches-and-meds-no-better-than-cold-turkey-quitting-40700">GP guide is wrong: patches and meds no better than cold turkey quitting</a>
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<p>In Australia, there are approximately <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/tobacco-kff">2.6 million</a> adult daily smokers, who have been estimated to cost the government <a href="http://www.health.gov.au/internet/drugstrategy/publishing.nsf/Content/34F55AF632F67B70CA2573F60005D42B/$File/mono64.pdf">A$31.5 billion</a> in social, health and economic costs each year. That’s about A$12,000 per smoker, which is much more than incentive programs offer.</p>
<h2>Why does it work?</h2>
<p>Quitting is hard - ask any smoker. Not only are the benefits, like other health behaviour changes, not immediate, but quitting smoking requires the smoker to go through a nasty period of withdrawal, while knowing the withdrawal symptoms could be immediately relieved by smoking.</p>
<p>Unlike other quit smoking programs using one or a combination of strategies (counselling, nicotine replacement therapy), incentives-based programs give the quitter the autonomy to choose the quit strategy that best suits them, and simply rewards them for their success. Importantly, incentives programs provide instant positive rewards for quitting.</p>
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<a href="https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186317/original/file-20170918-24084-1g0n2ju.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">People respond better when the rewards are instant.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/search/photos/eating-chocolate?photo=1Hh57OhkdCc">Toa Heftiba/Unsplash</a></span>
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<p>This phenomenon is described by behavioural economics as “<a href="http://ac.els-cdn.com/S0006322315001687/1-s2.0-S0006322315001687-main.pdf?_tid=9afda914-9774-11e7-9fbe-00000aab0f27&acdnat=1505191453_2617e1d8b845d2ba33d4ef0e594f2846">temporal discounting</a>”; a process explaining how humans have a preferential bias towards immediate reinforcement over delayed reinforcement, even if the delayed rewards are more valuable. Incentives therefore motivate quitters to stay on track in those difficult first few weeks of quitting smoking.</p>
<h2>So why don’t we do it?</h2>
<p>A common criticism of this type of intervention is that the targeted behaviour change is only maintained while the incentive is in place. Not only have incentives programs demonstrated long-term (one to two years) effectiveness superior to other treatment options, but even short-term behaviour change has important health implications.</p>
<p>Others are concerned people will “game” the program (say they’ve stopped smoking when they haven’t, or abstain from smoking just before verification). But research suggests this occurs in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413044/">less than 5% of cases</a>. After all, <a href="https://www.cdc.gov/mmwr/pdf/wk/mm6044.pdf">the majority</a> of smokers actually want to quit.</p>
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Read more:
<a href="https://theconversation.com/viewpoints-should-australia-lift-its-ban-on-e-cigarettes-28410">Viewpoints: should Australia lift its ban on e-cigarettes?</a>
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<p>Coersion and the ethical conundrum of free choice has been raised as an issue, with the concern that people will feel forced to sign up as they’ll be financially better off. But with a packet of cigarettes costing on average A$25 in Australia, the financial advantage of quitting seems to far outweigh the token financial incentive offered by such programs. </p>
<p>Finally, people have <a href="http://www.mamamia.com.au/pregnant-women-smoking/">voiced</a> their disapproval of a program that seemingly “rewards people for their bad behaviour”. Given the government subsidises medication to treat lifestyle-causing chronic conditions; it could be argued that this is much the same thing. </p>
<p>Tobacco control should not be about blaming and shaming people for a decision they made years ago that’s resulted in a life-threatening habit. It’s about reducing the devastating health and economic impact of tobacco smoking by adopting strategies that are proven to be safe and effective.</p><img src="https://counter.theconversation.com/content/84058/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mai Frandsen is a research fellow funded by Cancer Council Tasmania and the University of Tasmania. </span></em></p>Studies have found paying people to quit is more effective than other methods, so why are we not considering it in Australia?Mai Frandsen, Postdoctoral Research Fellow, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/648022016-09-06T20:09:31Z2016-09-06T20:09:31ZNicotine for vaping should be legalised in Australia: 40 international and Australian experts<figure><img src="https://images.theconversation.com/files/136531/original/image-20160905-31623-1fccpcr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">E-cigarettes are at least 95% less dangerous than tobacco cigarettes.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Forty leading international and Australian academics and researchers including myself have <a href="http://www.colinmendelsohn.com.au/tga">written to the Therapeutics Goods Administration</a> in support of an application to make low concentrations of nicotine available for use in electronic cigarettes (“vaping”).</p>
<p>In Australia, it is illegal to possess or use nicotine other than in tobacco or nicotine-replacement products, as nicotine is classified in the <a href="https://www.tga.gov.au/publication/poisons-standard-susmp">Poisons Standard</a> as a Schedule 7 “dangerous poison”.</p>
<p>As the primary addictive component of tobacco smoke, nicotine is part of the problem. However, it may also be part of the solution. Using clean nicotine in e-cigarettes provides smokers with an alternative way of getting the nicotine to which they are addicted without the tobacco smoke that causes <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">almost all of the harm from smoking</a>.</p>
<p>As well as delivering nicotine, e-cigarettes replicate several important aspects of the “smoking experience”. This includes the hand-to-mouth movement and the sensory and social aspects of the habit that smokers so often miss when they try to quit.</p>
<h2>How harmful is nicotine?</h2>
<p>The <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">health effects</a> of nicotine are relatively minor. It is <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">not a carcinogen</a> and does <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">not cause respiratory disease</a>. It has only relatively <a href="http://www.ncbi.nlm.nih.gov/pubmed/27079891">minor effects on the heart</a>, such as short-lived rises in heart rate and blood pressure, constriction of coronary arteries and an increase in the contracting of the heart muscle.</p>
<p>Nicotine in pregnancy <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">harms the baby’s developing brain</a> and lungs and reduces growth. <a href="http://www.surgeongeneral.gov/library/reports/50-years-of-progress/">It is also harmful</a> to the adolescent brain, delays wound healing and increases insulin resistance. There is <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3915512/">some evidence in laboratory studies</a> that nicotine may promote existing cancers.</p>
<p>However, when separated from the toxins in tobacco smoke and used in its pure form, there is <a href="http://www.ncbi.nlm.nih.gov/pubmed/14660766">little evidence of long-term harm</a> from <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725009/">nicotine exposure in humans</a> outside pregnancy and adolescence.</p>
<p><a href="https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update">Research</a> has <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">found</a> the health risks from vaping are unlikely to be more than 5% of the risk of smoking, and may well be substantially lower than this. As the vast majority of e-cigarette users are smokers or recent ex-smokers, this represents a huge health benefit for those who switch to vaping.</p>
<p>The effect of <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">vaping on bystanders</a> is also thought to be negligible. E-cigarettes release <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4565991/">low levels of nicotine</a> and minimal amounts of other chemicals into the ambient air. The expired vapour <a href="http://www.ncbi.nlm.nih.gov/pubmed/24267765">dissipates quickly</a> with no significant health risks to bystanders.</p>
<p>Recent research has found nicotine is <a href="http://www.ncbi.nlm.nih.gov/pubmed/24091634">much less toxic</a> than previously thought. Most cases of <a href="http://dx.doi.org/10.3109/15563650.2015.1102927">intentional overdose</a> with nicotine solutions result in prompt vomiting and full recovery. </p>
<p>Similarly, <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">accidental poisoning</a> in children typically causes mild adverse effects. Serious outcomes are rare. Most child poisoning with nicotine can be prevented with common sense, childproof packaging and warning labels, just like other potentially toxic medicines and cleaning products found in the home.</p>
<p><a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">Overseas experience</a> has shown e-cigarettes are not a gateway to smoking for young people. Although adolescents are experimenting with e-cigarettes, <a href="http://www.ncbi.nlm.nih.gov/pubmed/26250882">regular use by non-smokers is rare</a>. The great majority of adolescents <a href="https://www.drugabuse.gov/related-topics/trends-statistics/monitoring-future/overview-findings-2015/monitoring-future-figures-2015">use nicotine-free e-cigarettes</a>. </p>
<p>In fact, <a href="http://tobaccoanalysis.blogspot.com/2015/12/new-national-survey-refutes-cdc-claim.html">the evidence suggests</a> e-cigarettes are acting as an “exit gateway” and are displacing smoking. It is obviously better for young people not to use e-cigarettes, but vaping is preferable to smoking.</p>
<p>Smokers who are trying to reduce the health risks from smoking are using e-cigarettes almost exclusively as a safer alternative to combustible tobacco. After ten years of overseas’ experience, there is <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">no evidence</a> e-cigarettes are renormalising smoking, are undermining tobacco control or are being used to any significant extent for temporary, not permanent, abstinence (for example, in places where you can’t smoke).</p>
<h2>Why nicotine should be legalised</h2>
<p>Paradoxically, current Australian laws ban a less harmful form of nicotine intake (e-cigarettes) while allowing the widespread sale of the most lethal form of nicotine intake (tobacco cigarettes). In spite of the legal restrictions and difficulties of access, e-cigarette use has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/25358657">growing rapidly</a> in Australia.</p>
<p>Amending the Poisons Standard would allow smokers who are unable or unwilling to quit smoking to legally access low concentrations of nicotine for harm reduction. It is also legally used in nicotine-replacement therapies such as patches, so why not e-cigarettes? </p>
<p>Regulation under the Australian Consumer Law would improve product safety and quality, restrict sales to minors and ensure child-resistant containers and appropriate advertising. It would also eliminate the black market and the risks associated with it.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/27338716">A recent study</a> estimated over 6 million European Union citizens have used e-cigarettes to quit smoking. <a href="http://www.ash.org.uk/files/documents/ASH_891.pdf">In the UK</a>, 1.3 million ex-smokers are using an e-cigarette. Similarly, it is likely hundreds of thousands of Australians will quit smoking tobacco using e-cigarettes if nicotine is legally available.</p>
<p>After a full review of the evidence, <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">the Royal College of Physicians</a> (UK) recommended:</p>
<blockquote>
<p>in the interests of public health, it is important to promote the use of e-cigarettes […] as widely as possible as a substitute for smoking. </p>
</blockquote>
<p><a href="http://www.health.govt.nz/system/files/documents/publications/policy-options-e-cigarette-regulation-consultation-aug16.pdf">New Zealand</a> is working towards legalising nicotine-containing e-cigarettes. Australia needs to follow suit.</p><img src="https://counter.theconversation.com/content/64802/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>A/Prof Mendelsohn has no personal or commercial relationship with any electronic cigarette or tobacco company. He has received funding for teaching, consulting and conference expenses from Pfizer Australia, Glaxosmithkline and Johnson & Johnson Pacific.</span></em></p>Experts are petitioning the TGA to remove nicotine from the Poisons Standard so e-cigarettes can legally be used to quit smoking.Colin Mendelsohn, Associate professor, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/623472016-07-21T05:09:19Z2016-07-21T05:09:19ZHere’s how to close the gap on Indigenous women smoking during pregnancy<figure><img src="https://images.theconversation.com/files/131314/original/image-20160721-31156-yomlhx.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Indigenous women who smoke are well aware of the risks for their babies and want to do something about it. </span> <span class="attribution"><span class="source">Ray Kelly</span></span></figcaption></figure><p><a href="http://www.aihw.gov.au/publication-detail/?id=60129553770">Almost half of pregnant Indigenous women smoke</a> compared to one in eight in the non-Indigenous population. This means 7,000-9,000 Indigenous Australian babies every year are exposed to smoking in the womb.</p>
<p>Children exposed to tobacco smoke before birth are at increased risk of “<a href="http://www.abc.net.au/health/library/stories/2003/03/27/1831084.htm">glue ear</a>”, which causes hearing loss, learning problems and behavioural problems. They are also at greater risk of asthma and <a href="http://www.rch.org.au/kidsinfo/fact_sheets/bronchiolitis/">bronchiolitis</a> in childhood, and chronic lung disease in adulthood. </p>
<p>Children born to mothers who smoke are <a href="https://www.researchgate.net/publication/273951863_Predictors_of_intentions_to_quit_smoking_in_Aboriginal_tobacco_smokers_of_reproductive_age_in_regional_New_South_Wales_NSW_Australia_Quantitative_and_qualitative_findings_of_a_cross-sectional_survey">more likely to become smokers</a>. Some try smoking as young as five years old.</p>
<p><a href="http://www.womenandbirth.org/article/S1871-5192%2813%2900109-1/pdf">Our research shows</a> women are well aware of the risks of smoking for their babies, and <a href="http://www.menzies.edu.au/icms_docs/wicc2016_concurrentsession_6_Bovill.pdf">want to do something</a> about it. </p>
<p><a href="http://dx.doi.org/10.1071/PY15066">We have identified</a> three key areas that need urgent remediation if Indigenous women are to be effectively supported to quit:</p>
<ul>
<li><p>subsidised access to oral forms of nicotine replacement therapy</p></li>
<li><p>clinician training to better manage smoking during pregnancy</p></li>
<li><p>health promotion messages to address the challenges Indigenous women face when quitting.</p></li>
</ul>
<h2>Access to nicotine replacement therapy</h2>
<p><a href="http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/">Australian GP guidelines</a> recommend if a woman cannot quit smoking during pregnancy or when breastfeeding, she should be offered oral forms of nicotine replacement therapy (NRT), such as inhalers or lozenges. These are <a href="http://www.racgp.org.au/afp/2014/januaryfebruary/smoking-in-pregnant-women/">faster-acting</a> than nicotine patches and should be considered the first-line treatment.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=735&fit=crop&dpr=1 600w, https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=735&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=735&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=924&fit=crop&dpr=1 754w, https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=924&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/131333/original/image-20160721-31129-szi3c8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=924&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Consumers have to pay around A$800 for a 90-day course of an inhaler.</span>
<span class="attribution"><span class="source">Ray Kelly</span></span>
</figcaption>
</figure>
<p>Patches are listed on the Pharmaceutical Benefit Scheme (PBS), but oral NRT (inhalers, lozenges, gum and nicotine spray) is not listed or subsidised. These options are expensive when bought in retail outlets. A full, 12-week course costs around A$500 for the nicotine spray or lozenges, and A$800 for the inhaler.</p>
<p>For the past three years, I have lobbied the government and pharmaceutical companies to remediate this. Because patches are already listed, putting oral NRT on the PBS would involve only a minor change to add extra products to the listing.</p>
<p>But while the government may be willing, the pharmaceutical companies are reluctant to repackage these products for prescription use. My investigations reveal pricing is a key factor: the government is unlikely to pay as much for PBS-listed products as pharmaceutical companies expect. </p>
<p>PBS representatives stepped in to do their own negotiations with pharmaceutical companies, but these appear to be gridlocked.</p>
<h2>Health professional training</h2>
<p>We recently surveyed 378 Australian GPs and obstetricians and found <a href="https://www.researchgate.net/publication/291973916_Evidence-practice_gaps_for_Australian_general_practitioners_GP_and_obstetricians_in_assisting_pregnant_women_to_quit">few are confident</a> to prescribe NRT to pregnant women. Of the respondents: </p>
<ul>
<li><p>88% said NRT was safer than smoking</p></li>
<li><p>66% considered NRT moderately to highly effective</p></li>
<li><p>11% always prescribed NRT to a pregnant smoker</p></li>
<li><p>63% agreed management would improve if oral NRT was on the PBS</p></li>
<li><p>78% agreed further training was required.</p></li>
</ul>
<p>In <a href="http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-165">another study</a>, some health workers did not consider it worthwhile to offer quit advice to Indigenous pregnant women, due to low success rates.</p>
<p>To overcome these barriers, we are developing a webinar intervention with six Aboriginal Community Controlled Health Services on how to manage smoking during pregnancy. The Indigenous Counselling and Nicotine (ICAN) Quit in Pregnancy program will use an <a href="https://www.researchgate.net/publication/288737387_Indigenous_Counselling_and_Nicotine_ICAN_QUIT_in_Pregnancy_-_developing_an_evidence-based_intervention_for_smoking_cessation_for_Indigenous_pregnant_women">ABCD approach</a>:</p>
<ul>
<li><p>ask/assess smoking</p></li>
<li><p>brief advice to quit</p></li>
<li><p>cessation (quit) methods (nicotine replacement therapies, which will be provided at no charge)</p></li>
<li><p>discuss the <a href="https://www.researchgate.net/publication/261216825_A_Pragmatic_Guide_for_Smoking_Cessation_Counselling_and_the_Initiation_of_Nicotine_Replacement_Therapy_for_Pregnant_Aboriginal_and_Torres_Strait_Islander_Smokers">psychological and social context</a> of smoking. </p></li>
</ul>
<p>“D” is crucial to understanding and effectively supporting a pregnant Indigenous smoker to quit. The <a href="https://www.researchgate.net/publication/288737387_Indigenous_Counselling_and_Nicotine_ICAN_QUIT_in_Pregnancy_-_developing_an_evidence-based_intervention_for_smoking_cessation_for_Indigenous_pregnant_women">intervention will be trialled</a> in three to four states. If successful, it can be easily scaled up nation-wide.</p>
<h2>New health promotion messages</h2>
<p>A wealth of evidence has amassed in the past five years to better inform messages around Indigenous women smoking during pregnancy. It’s time to translate this knowledge into practice. </p>
<p>Many Indigenous women face difficult life circumstances, coupled with social norms of smoking. Health promotion programs and messages <a href="http://dx.doi.org/10.1071/PY15066">must account for these circumstances</a> and focus on key messages. These include:</p>
<ul>
<li><p>increasing the visibility of harm for babies</p></li>
<li><p>addressing the importance of quitting rather than just “cutting down” – making quitting seem worth it</p></li>
<li><p>reassuring that stress will decrease once nicotine withdrawal is controlled</p></li>
<li><p>offering high-quality support – women need to know they are not alone and can be helped.</p></li>
</ul>
<p>Health promotion programs should be delivered to women through targeted print and film media, and during the consultation at primary care services. </p>
<p>Indigenous women must have an opportunity to address their smoking when pregnant. They need to be supported by making essential medications easily available and affordable, building capacity by training health professionals, and getting a broad reach for the right messages to this high-priority group. This way we can start to move forward and close the gap in this area.</p><img src="https://counter.theconversation.com/content/62347/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gillian Sandra Gould receives funding from NHMRC, CINSW, Hunter Cancer Research Alliance, University of Newcastle, Royal Australian College of General Practitioners (RACGP) Foundation, Ministry of Health NSW, John Hunter Hospital Charitable Foundation. She is affiliated with the Australian Association of Smoking Cessation Professionals, the RACGP, the Australian Medical Acupuncture College, and Australasian Society for Behavioural Health and Medicine. </span></em></p>Almost half of pregnant Indigenous women smoke compared to one in eight in the non-Indigenous population. This means 7,000-9,000 Indigenous babies every year are exposed to smoking in the womb.Gillian Sandra Gould, NHMRC Research Fellow and CINSW Research Fellow, Centre for Brain and Mental Health Research, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/610072016-06-14T06:38:31Z2016-06-14T06:38:31ZIs nicotine really as safe as e-cigarette supporters make out?<p>A core platform of the massive promotion of e-cigarettes has been the argument that because these products involve no combustion but only vapourisation, they must be substantially less dangerous than smoked tobacco. Few – including me – would disagree with that. There’s no carbon monoxide with vaping and none of the deadly <a href="https://en.wikipedia.org/wiki/Pyrolysis">pyrolysis</a> products generated by the partial decomposition of carbon matter and flavouring chemicals in tobacco when it is burned.</p>
<p>But as <a href="https://www.researchgate.net/publication/289674033_On_the_Safety_of_E-cigarettes_I_can_resist_anything_except_temptation1">toxicologists</a> have pointed out, the long-term consequences of inhaling an average of <a href="http://ajplung.physiology.org/content/early/2016/06/07/ajplung.00170.2016">200 and up to 600 times a day</a> a soup of vaporized flavouring and other chemicals approved for ingestion but not inhalation will not be known for many years.</p>
<h2>‘As safe as coffee’?</h2>
<p>The widely publicised “95% less dangerous than smoking” figure in the <a href="https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review">Public Health England</a> report on the safety of e-cigarettes can be nothing but a fingers-crossed guess. <a href="http://www.bmj.com/content/351/bmj.h5826/infographic">Questions have also been raised</a> about the panel that came to that figure and potential conflicts of interest.</p>
<p>A fundamental appeal of e-cigarettes is they are a “clean” nicotine delivery system. But there is also a widespread effort underway to depict nicotine as a benign drug. </p>
<p>Three prominent advocates for e-cigarettes, psychologists Robert West and Peter Hajek (who together have registered a patent for a nicotine delivery invention) and Professor John Britton, Chair of the Tobacco Advisory Group of the Royal College of Physicians, are among many who have made public statements suggesting nicotine is as close to benign as one could imagine. </p>
<p><a href="http://www.theguardian.com/society/2013/jun/04/e-cigarettes-health-revolution-smokers?view=mobile">Professor Robert West</a> has said: </p>
<blockquote>
<p>E-cigarettes are about as safe as you can get. We know about the health risks of nicotine from studies in Sweden into the use of snus, a smokeless tobacco. Nicotine is not what kills you when you smoke tobacco. E-cigarettes are probably about as safe as drinking coffee. All they contain is water vapour, nicotine and propylene glycol</p>
</blockquote>
<p><a href="http://www.thetimes.co.uk/tto/opinion/letters/article3667478.ece">Professor Peter Hajek</a> has said:</p>
<blockquote>
<p>Nicotine itself is probably safer than caffeine […] The case for regulating e-cigarettes as a pharmaceutical product is on a par with regulating coffee</p>
</blockquote>
<p>And <a href="http://www.bbc.co.uk/news/uk-21406540">Professor John Britton</a>:</p>
<blockquote>
<p>Nicotine itself is not a particularly hazardous drug […] It’s something on a par with the effects you get from caffeine.</p>
</blockquote>
<p>But there is extensive research in stark contrast to these statements. Earlier this year, the Lancet published a <a href="http://thelancet.com/pdfs/journals/lanpsy/PIIS2215-0366(15)00152-2.pdf">systematic review</a> of tobacco use and psychosis. It has long been known that people with psychosis (including schizophrenia) have high smoking rates (although <a href="http://www.ncbi.nlm.nih.gov/pubmed/19221917">citation bias</a> has caused studies reporting extreme rates to dominate discussion and public accounts of this issue). The traditional explanation of their higher smoking has always been that people with psychosis self-medicate with nicotine to relieve boredom or distress.</p>
<p>However, the Lancet review considered whether smoking might somehow play a role in the development of psychosis. The authors found that in five longitudinal prospective studies, the risk of psychotic disorder was increased modestly by daily smoking. The open access review discusses why nicotine is the plausible factor in smoking that is likely to be explanatory.</p>
<p>Last month a new study was published by the <a href="http://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2016.15060800">American Journal of Psychiatry</a> examining the association between maternal blood cotinine levels (a metabolite of nicotine) drawn twice during pregnancy and subsequent diagnosis of schizophrenia in all children born in Finland from 1983-1998.</p>
<p>Finland has long had highly advanced record linkage for all citizens, and 98% of all mothers who had live births across this 16 year period gave serum samples. Some 977 cases of diagnosed schizophrenia in this birth cohort were identified and these were matched with controls (without schizophrenia) for date of birth (within one month), sex, and residence in Finland at the time of case schizophrenia diagnosis.</p>
<p>The study found heavy maternal nicotine exposure was related to a 38% increased odds of schizophrenia in offspring and these findings were not explained by maternal age, maternal or parental psychiatric disorders, socioeconomic status, or other covariates. </p>
<p>Senior staff at the US government’s Office on Smoking and Health have <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4594223/pdf/nihms724908.pdf">summarized evidence</a> on nicotine’s role in many health problems including impaired foetal brain and lung development, and altered brain development in adolescents. </p>
<p>Other authors have focused particularly on concerns about the importance of avoiding nicotine exposure in <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656811/">pregnancy</a>, including via <a href="http://www.ncbi.nlm.nih.gov/pubmed/18380035">nicotine replacement therapy</a>.</p>
<p>In the US, e-cigarettes are now <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a3.htm">more commonly used</a> by high school students than are cigarettes. Messages about nicotine being virtually risk free may be encouraging this rapid uptake.</p>
<h2>What about cancer and nicotine?</h2>
<p>Nicotine is not classified as a carcinogen, but there is considerable evidence it functions as a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22050423">tumour promoter</a> or “<a href="http://www.ncbi.nlm.nih.gov/pubmed/17846896">enhancer</a>” and that it might contribute to the <a href="http://www.ncbi.nlm.nih.gov/pubmed/18495523">progression of tumors</a> already initiated. </p>
<p>As many tumours are indolent and do not progress, tumour promoters are of great concern. In April 2014, the International Agency for Research in Cancer (IARC), widely acknowledged as the world’s leading agency for developing consensus on the carcinogenicity of chemicals and environmental pathogens, published <a href="http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70168-8/abstract">a list of high and medium priority candidates</a> for assessment as carcinogens between 2015-2019. </p>
<p>Nicotine was one of the high priorities with the notation stating there is an association between exposure to nicotine via electronic nicotine delivery systems and DNA damage and other pathways of carcinogenesis.</p>
<p>The sort of data IARC would have been referring to have been summarised in <a href="http://www.nature.com/nrc/journal/v14/n6/pdf/nrc3725.pdf">recent reviews</a> that found the number of cancers reportedly connected to nicotine is on the rise. </p>
<p>These include small-cell and non-small-cell lung carcinomas, as well as head and neck, gastric, pancreatic, gallbladder, liver, colon, breast, cervical, urinary bladder and kidney cancers.</p>
<h2>So why is it approved in nicotine replacement therapy?</h2>
<p>It is well known many smokers find nicotine replacement therapy unsatisfactory in that it does not supply them with sufficient nicotine to overcome their cravings. </p>
<p>In 2006 I spoke to a senior researcher who had previously worked for a major pharmaceutical company at the forefront of nicotine replacement therapy. I asked her why companies did not produce higher nicotine delivery products which would stand a better chance of substituting for cigarettes. </p>
<p>She told me pharmaceutical companies were acutely aware nicotine was not a benign drug, and they were highly sensitive to the risks involved in trying to get higher delivery nicotine replacement therapy approved for use, and had collectively decided not to go down that path. The US Food and Drug Administration would have almost certainly rejected such applications, she said.</p>
<p>Could it be part of the business model for nicotine replacement therapy that the dosage which might actually succeed in helping many smokers quit would not be as profitable as the dosage levels that saw high failure rates and many smokers having to repeat attempts with current and newer formulations?</p>
<p>The IARC’s planned assessment of nicotine’s status as a possible carcinogen or cancer promoter will be an important milestone in the emerging picture of e-cigarettes and their risks and benefits to public health.</p><img src="https://counter.theconversation.com/content/61007/count.gif" alt="The Conversation" width="1" height="1" />
<h4 class="border">Disclosure</h4><p class="fine-print"><em><span>Before retiring from employment with the University of Sydney the author contributed to an options paper on the regulation of Electronic Nicotine Delivery Systems commissioned by the Department of Health, Canberra. He wrote a first draft of a section on their use in smoking cessation.</span></em></p>A core platform of the massive promotion of e-cigarettes has been the argument that because these products involve no combustion but only vapourisation, they must be substantially less dangerous than smoked…Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/417492015-11-06T03:17:44Z2015-11-06T03:17:44ZDespite help on offer, many smokers prefer to quit on their own – here’s why<figure><img src="https://images.theconversation.com/files/98336/original/image-20151013-882-11i5xah.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Quitting on their own can help some smokers feel autonomous, independent and in control.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/pireusplus/440159833/">Skywalker++/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>If you smoke more than ten cigarettes a day or have experienced cravings while trying to quit, your doctor has probably <a href="http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/">recommended</a> a cigarette substitute such as nicotine patches or gum to help you.</p>
<p>But <a href="http://bmjopen.bmj.com/content/5/4/e007301.full">our research</a> suggests most Australians don’t want to quit smoking this way, and continuing to make these substitutes (pharmacotherapy) more affordable and readily available is not necessarily going to persuade smokers to quit.</p>
<p>Pharmacotherapies are government-subsidised and widely available to all Australian smokers. Nicotine-replacement therapy (such as gum) has been available from pharmacies since 1997. </p>
<p>Zyban®, an oral prescription drug to reduce cravings and other withdrawal symptoms, has been subsidised via the Pharmaceutical Benefits Scheme (PBS) since 2001. Champix®, a drug that reduces the pleasure from smoking, has been available since 2008. Patches have been subsidised on the PBS since 2011. </p>
<p>Even supermarkets and convenience stores have sold nicotine-replacement therapies since 2006. </p>
<p>This is all based on the assumption by researchers and health-care practitioners that if we provide smokers with effective interventions they will <a href="http://www.ajpmonline.org/article/S0749-3797(09)00880-0/abstract">seek them out</a> to quit smoking.</p>
<p>Turns out, they often don’t. The majority of smokers in Australia <a href="http://tobaccocontrol.bmj.com/content/early/2013/09/06/tobaccocontrol-2013-051019">still choose</a> not to use assistance to quit. Approximately half to two-thirds quit unassisted and about half who attempt to quit do so unassisted. </p>
<h2>The importance of experience</h2>
<p><a href="http://bmjopen.bmj.com/content/5/4/e007301.full">Our research</a> tried to understand why this is the case. We found the knowledge of other smokers and ex-smokers was far more influential for people trying to quit than expert or research-based knowledge. </p>
<p>Smokers trade off the pros and cons of quitting with or without assistance. Unassisted quitting often wins as it is seen as a more convenient way to quit.</p>
<p>Smokers and ex-smokers trade stories about their experience of quitting, and have their own personal experience to draw on. This often conflicts with what they have been told about assistance by their doctor, pharmacist or through marketing by pharmaceutical companies.</p>
<p>Experts tell smokers that assistance will work. But when smokers try it, it often doesn’t, or at least not in the way they expected. This is unsurprising, as the likelihood of succeeding in any single quit attempt is quite low, whether or not you use assistance. Most smokers will quit eventually, but only after a number of failed attempts. </p>
<p>If you quit without assistance, you have a <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2004.00540.x/full">one-in-20 chance</a> of success. If you try quitting with assistance, your chance of success doubles, but that is still only a <a href="http://jama.jamanetwork.com/article.aspx?articleid=1812940">one-in-ten chance</a>. </p>
<p>When the official message about quit assistance conflicts with their personal experience, smokers unsurprisingly give preference to their prior knowledge and that of other smokers. </p>
<h2>The right way?</h2>
<p>Researchers and experts tend to see <a href="http://ntr.oxfordjournals.org/content/early/2012/11/05/ntr.nts164.short">unassisted quitting</a> as the poor cousin to assisted quitting. But from a smoker’s perspective it has real advantages. It allows you to define yourself as a non-smoker straight away, instead of having a messy “treatment” period when you are neither a smoker nor a non-smoker. </p>
<p>Using assistance requires the adoption of new — but temporary — routines and habits. This feels like a waste of energy and attention for people who want to get on with establishing the habits and routines of being a non-smoker. For many, spending money on nicotine-replacement therapies, which would keep you addicted to nicotine, just did not make sense.</p>
<p>Smokers often talk about quitting unassisted as being “the right way” or “a better way” to quit. This contrasts with the dominant <a href="http://www.sciencedirect.com/science/article/pii/S0749379707005612">health promotion</a> and medical discourse in <a href="http://search.informit.com.au/documentSummary;dn=330074269473620;res=IELHEA">Australia</a> and the <a href="http://www.sciencedirect.com/science/article/pii/S0140673609604177">United Kingdom</a>, which tends to frame quitting with assistance as being the better or more logical choice for smokers who want to quit. Some even frame quitting unassisted as <a href="http://www.bhamcommunity.nhs.uk/about-us/services/adults/stop-smoking/campaigns-and-resources/cold-turkey/">being foolhardy or unwise</a>.</p>
<p>Underlying these beliefs may be a set of values that certain smokers and perhaps society as a whole endorse. These include independence, strength, autonomy, self-control and self-reliance. Our research showed many smokers believe they have achieved something of value by quitting unassisted. They appear to take this achievement as an indicator of the strength of their moral character, or evidence of personal virtue. </p>
<p>Quitting smoking offers enormous health benefits. Some people need help to do it and it should be easy for them to access it. But it is not the be all and end all of quitting. Benefits of getting help vary and many smokers who try assistance will go on to successfully quit unassisted. </p>
<p>Our research shows that if health professionals want smokers to trust their advice, they would do well to do two things. First, avoid overselling smoking cessation assistance. And second, be careful not to buy into the idea that people who quit unassisted are “better people”.</p><img src="https://counter.theconversation.com/content/41749/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Smith receives funding from the National Health and Medical Research Council of Australia.</span></em></p><p class="fine-print"><em><span>Stacy Carter receives funding from the National Health and Medical Research Council. </span></em></p>New research suggests most smokers don’t want to quit using nicotine replacement, they want to do it on their own.Andrea Smith, Doctoral Candidate and Research Associate, University of SydneyStacy Carter, Associate Professor, Centre for Values, Ethics and the Law in Medicine, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/274442014-06-03T04:43:50Z2014-06-03T04:43:50ZElectronic cigarettes: hope from the hype may harm your health<figure><img src="https://images.theconversation.com/files/49973/original/zy9kj3d8-1401689873.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's highly likely many vapers who continue to smoke do so because they've convinced themselves that cutting down on cigarettes has significantly reduced their risk.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/23748404@N00/9617375991">A. Currell/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>A <a href="http://onlinelibrary.wiley.com/store/10.1111/add.12623/asset/add12623.pdf?v=1&t=hvxe0r30&s=c5f70101ba1c7c22670f485fbc81eb5de136dc35">UK study published online</a> in the journal Addiction has generated headlines proclaiming electronic cigarettes as an established new way to reduce the harms of smoking or quit altogether. But such claims are not only premature, they may be all smoke and mirrors.</p>
<p>Two of the biggest promises feeding the fervour for electronic cigarettes (e-cigs) are that they knock the socks off other ways of quitting smoking and that they’re a terrific way of reducing harm because “vaping” as it’s known, can reduce the number of cigarettes regular smokers consume. </p>
<p>But do electronic cigarettes actually help smokers quit?</p>
<p>Globally, there are probably hundreds of thousands of people who quit smoking by vaping. Many argue it’s their experience that counts, but the plural of anecdote isn’t evidence. Many people drive intoxicated every day without having car accidents, for instance, but that doesn’t count as evidence that driving under the influence of alcohol is safe. </p>
<h2>Fuzzy numbers</h2>
<p>Most studies on quitting cigarettes using e-cigs are almost worthless for smokers at large because they’re drawn from non-representative populations, such as vaping chatrooms. </p>
<p>Data from such research tend to show sometimes stratospheric success levels (<a href="http://ecigarette-research.com/web/index.php/research/2014/152-world-survey">this one</a>, for instance, reported 81% quitting). But basing knowledge on the experiences of those for whom vaping is a major part of life is like polling active members of a wine appreciation society to understand community-wide drinking patterns. </p>
<p>And perish the thought that dedicated vaping advocates, including many with commercial interests, would ever stack a survey or tell pork pies to help their cause.</p>
<p>The Addiction study published last week is by far the <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.12623/pdf">most important study</a> on how smokers use e-cigarettes. </p>
<p>This “real world” English study examined 5,863 smokers who’d made a quit attempt in the past year. It found 93 out of the 464 people who used e-cigarettes were successful (20%), while 194 out of the 1,922 people using nicotine replacement therapy made it (10.1%), and 535 out of 3,477 of the people trying to quit unassisted did so (15.4%). </p>
<p>Let’s look at these numbers another way. In this large study, 80% of smokers trying to quit by vaping were still smoking compared with 84.6% of those tried to quit on their own. That hardly looks like a champagne-popping difference deserving the accolades abounding in narratives about vaping.</p>
<p>And, of course, many of the quitters relapse weeks or months after completing the questionnaire, so the figures become less flattering over time. We know that, because of relapse, those quitting unassisted or with nicotine replacement therapy bought over the counter have about 4% continuous abstinence at 12 months. </p>
<p>We don’t have any data yet on relapses by e-cigarette users, but if we assume they do so at the same rate (cue vapers vehemently insisting that this is not true for vaping), then we might expect a tiny fraction over this 4%, regardless of method used, to be still not smoking a year later. </p>
<h2>Misunderstood benefits</h2>
<p>The most common outcomes of smokers vaping are that they smoke and vape at the same time (dual use rather than vaping instead of smoking) and they reduce the number of cigarettes smoked each day.</p>
<p>So isn’t this reduced smoking a major public health benefit for e-cigarettes?</p>
<p>Here, there’s a counter-intuitive paradox. There’s no disagreement about there being a dose-response relationship between the amount smoked and risk of disease. That is, the worst risk applies to people who start smoking early, smoke for a long time and smoke heavily. </p>
<p>So it sounds entirely reasonable to assume that people who cut down the number of cigarettes they smoke each day reverse that risk and reduce harm. But that’s far from what studies that follow large groups of smokers over many years have found. </p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/17130377">30-year Norwegian study</a> of 51,210 adults, for instance, found:</p>
<blockquote>
<p>Long term follow-up provides no evidence that smokers who cut down their daily cigarette consumption by more than 50% reduce their risk of premature death significantly. </p>
</blockquote>
<p>While a <a href="http://www.ncbi.nlm.nih.gov/pubmed/12446255">Danish study</a> of 19,737 people with 15 years follow-up concluded “smoking reduction is not associated with a decrease in mortality from tobacco-caused diseases.” Two <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=Bauld+Hart+smoking">long-term Scottish studies</a> concluded “reducing smoking consumption should not be promoted as a means of reducing mortality.” </p>
<p>And the largest of this type of research, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/18838704">Korean study with 479,156 people followed for 11 years</a> found:</p>
<blockquote>
<p>No association between smoking reduction and all-cancer risk and that smoking reduction was associated with significant decrease in the risk of lung cancer, but size of risk reduction was disproportionately smaller than expected.</p>
</blockquote>
<p>Finally, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/17558820">systematic review</a> of all smoking-reduction studies published before data from most of the above large studies were available, noted the studies were small and that a “substantial reduction seems to have a small effect” on mortality. </p>
<p>All studies reported that stopping smoking altogether had a significant impact on mortality.</p>
<p>Clearly, dual users who think they’re reducing their risk of death by smoking less are not basing their hopes on good evidence. And what we don’t know is how many smokers now using both would have quit altogether in the absence of electronic cigarettes. It’s highly likely many vapers who continue to smoke do so because they’ve convinced themselves that cutting down on cigarettes has significantly reduced their risk.</p>
<p>Meanwhile, headlines about the English study should probably have said there were nearly six times as many smokers who quit without any assistance than vapers who did. </p>
<p>The radical news that deserves shouting from the rooftops is that going cold turkey has always been the the method used by more successful quitters than any other method.</p><img src="https://counter.theconversation.com/content/27444/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman is a co-investigator with three others on NHMRC project grant #1024459 "The natural history of unassisted smoking cessation in Australia."</span></em></p>A UK study published online in the journal Addiction has generated headlines proclaiming electronic cigarettes as an established new way to reduce the harms of smoking or quit altogether. But such claims…Simon Chapman, Professor of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.