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Nicotine replacement therapy isn’t all it’s cracked up to be

A study published in the latest edition of the journal Tobacco Control confirms what we’ve long suspected about nicotine replacement therapy (NRT): smokers don’t need to resort to these pharmaceuticals…

New concerns have been raised over the effectiveness of nicotine replacement therapy. Image from shutterstock.com

A study published in the latest edition of the journal Tobacco Control confirms what we’ve long suspected about nicotine replacement therapy (NRT): smokers don’t need to resort to these pharmaceuticals to quit.

Researchers at the Harvard School of Public Health and the University of Massachusetts analysed relapse rates among 787 Massachusetts smokers who had recently quit, in three waves of interviews between 2002 and 2006. Participants were asked how they quit smoking, if they used NRT and in which form - gum, patch or inhaler. They were also asked to describe the longest period of continuous use of the product and if they received any form of cessation counselling.

Accounting for variation by gender, race, age, education and level of nicotine dependence, the researchers found that people who relapsed into smoking did so at equivalent rates, whether or not they had used NRT to assist in their quit attempt.

The findings add to the growing literature that questions the effectiveness of NRT to help people quit smoking.

What does the evidence say?

Clinical trials have reported that NRT increases the success rate of quitting by 50% to 70% compared to those receiving placebo. But these impressive results have not been replicated in real-world settings. Population-level studies have found no beneficial effect of the use of nicotine replacement therapy.

Selection criteria covering trial participants and the terms of their participation are among the key reasons for the marked difference in findings.

Research shows that unassisted cessation, or cold turkey, remains the most successful method of quitting. Yet questions about the efficacy of NRT often provoke intense debate within the tobacco control community, with clear implications for countries with high smoking rates which are yet to implement comprehensive tobacco-control regulations.

Perceptions of the effectiveness of NRT are also relevant to Australia and other countries that have enacted advanced legislation. Australia’s adult smoking rate is at a historic low of 15.1%, but tobacco consumption remains a leading public health concern. Some 3.3 million adults continue to smoke daily or weekly, and 15,000 Australians die annually from smoking-related diseases. The total social cost to the national economy is estimated to be $31.4 billion.

More than 15,000 Australians die annually from a smoking-related diseases. Image from shutterstock.com

Tobacco control policy

Despite the growing evidence of the limitations of NRT in “real-world” situations, pharmaceutical patches, inhalers and gums continue to play a key role in smoking cessation policy.

The Quit Victoria website states that smokers “who have the best chance of quitting are those who get some coaching and use quitting medications”; while NSW Health says proper use of NRT products can be “the key to successfully quitting for good."

The Commonwealth Department of Health and Ageing’s National Tobacco Campaign states that smokers can double the chances of quitting successfully by using cessation medication, but questions the veracity of ex-smokers’ claims to have quit without medication:

Though many people will say that they have quit cold turkey, often they have used medication or advice and support to help them through.

Support for NRT has been translated into government policy, following a submission to the Pharmaceutical Benefits Advisory by Cancer Council Australia, Heart Foundation, Australian Council on Smoking, and Health and Quit Victoria. Nicotine patches have been subsidised on the Pharmaceutical Benefits Scheme as a prescription smoking-cessation aid since 2011, at a cost of $9 million in the first year of subsidisation.

Another promoter of NRT is, of course, the pharmaceutical industry. The 2011 global sales of NRT were worth an estimated US$2.4 billion. In Australia, patches, gum, and other forms of NRT have been available over the counter for years, and the market continues to expand. Sales increased by 7% in 2011 to $174 million, and market analysts predict continuing strong sales, due in part to the growing range of NRT products available in supermarkets.

Time for evidence-based policy

Pharmaceutical cessation products continue to attract support disproportionate to their usefulness. This distracts attention from the reality that the most common method used by most ex-smokers remains unassisted cessation.

Perhaps most importantly, it threatens funding for evidence-based population level interventions – such as tax increases and media campaigns – that have been primarily responsible for the precipitous drop in smoking rates in Australia in recent decades.

Join the conversation

31 Comments sorted by

  1. Craig Minns

    Self-employed

    Excellent article that agrees with my own experience of stopping smoking 20 years ago this year. It seems to me that the psychology of the smoker has to be engaged in the process and the "Quit" and substitution campaigns are engaging a psychological mechamism that is at odds with the expressed aims. In my case, I was smoking 2+ packs of rollies a week (as well as a couple of packs of tailors for the car and had "given up" many times, then relapsed, which I found both frustrating and depressing. Musing…

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    1. Emma Anderson

      Artist and Science Junkie

      In reply to Craig Minns

      I can articulate how this relates to some behaviorist ideas as well as my experience as a smoker who stopped for two years and relapsed. I will stop again.

      What you're basically saying here is the conundrum I face in my previous attempts for the 2 year cessation. It felt like a loss of something, rather than a gain. Quitting is as you say, giving up, losing.

      In behaviorist terms it's a negative punishment to stop smoking. We are removing something that punishes our health. But we are also…

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  2. Tim Traynor

    Rocket Surgeon

    They just need to stop. Really, it's not that hard.

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    1. Michael Hay

      retired

      In reply to Dennis Alexander

      Dennis: I smoked for 50 years. RYO and then a pipe because the increasing manufacture of filtered cigarettes gave me no satisfaction; they were known as 'puff and blow' cigarettes. I had a heart attack - and went on smoking when I came home; I had a by-pass operation and a tin valve replacement and found it was domestically expedient to stop using tobacco. So I stopped: just like that; decision made.

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    2. Michael Hay

      retired

      In reply to Michael Hay

      The rest of my comment is that I do not believe that nicotine is necessarily addictive. Smoking is a social habit and habits can be broken. The wish to smoke has two basic drivers.
      1. Laziness: it is easier to continue than to stop and the sensation of smoking is pleasant and relaxing. So why stop something so pleasurable?
      2. The desire to have something in one's mouth. Some ex-smokers chew snacks,and get fat; some chew celery stalks. I chewed my empty pipe and my weight did not increase!
      So the "addiction" can be cured by taking control of one's mind - which nullifies the parameters of an addiction. QED!

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    3. In reply to Michael Hay

      Comment removed by moderator.

    4. Dennis Alexander

      logged in via LinkedIn

      In reply to Tim Traynor

      No Tim, I have not got a weal mind and neither am I stupid - you really don't want to go down that path given the number of Nobel Laureates that smoked, even as the evidence mounted. You are either ignorant of the facts or a troll, take your pick.

      And Michael, the mechanisms of adrenalin addiction are well known and documented - adrenalin is what is released in response to the poiwson nicotine - and while any addiction can be "cured" by simple abstinence, it is because abstinence is not a cure that AA does not accept that an alcoholic is ever a former alcoholic.

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    5. Felix MacNeill

      Environmental Manager

      In reply to Dennis Alexander

      Yup - top film.

      While we're on the subject of smoking, though, my experience as a nicotine addict in long term remission is that while nicotine is directly addictive, the simple physical addiction passes after a week or two (granted, on day three one can be slightly less than sweet-tempered and reasonable, but it does pass).

      But I think the deeper addiction is more psychological Yes, it's partly social (though I still smoked just as heavily on my own) but there are subtler factors. For one…

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    6. Emma Anderson

      Artist and Science Junkie

      In reply to Michael Hay

      I think having gone through all of that health drama makes a big difference to the overall state of mind you were in when you stopped.

      For instance, and definitely correct me if I am wrong here, but "domestic expedience" may have been the observed rationale, but simultaneously you'd also had proof that this stuff was bad for you. It was no longer "something that might happen" but something that did, and any comfort you could derive from what remained of your health was not going to come from smoking.

      For people who are let's say 25, sometimes older, who have no obvious related health problems, all that stuff on the ciggy packets is just scare tactics. It's not real. "Yeah it might happen, later, might also get hit by a bus, too" is rationale I've used in the past and observed in other smokers.

      Did you do that?

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    7. Amanda Robertson

      logged in via Facebook

      In reply to Dennis Alexander

      Hi Dennis,

      It's funny, I agree with you and I agree with Tim. To explain, I smoked for 20+ years and tried many times to quit over that period. I used NRT numerous times, tried cold-turkey or "will-power" (apparently I had none), I also tried hypnosis numerous times and nothing seemed to help. Considering the time, effort and money that I spent, I can't believe that I wasn't serious about quitting, I just *couldn't* do it. I smoked through my first pregnancy and lied about it because I hated myself…

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    8. Craig Minns

      Self-employed

      In reply to Amanda Robertson

      I must have a much more direct psychology. All I needed to grasp was that smoking is bad for me and smoking is something that requires my willing cooperation.

      If I withhold that cooperation, then no smoking happens.

      It takes more effort and directed motion to smoke than not to smoke, which is the default.

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    9. Michael Hay

      retired

      In reply to Emma Anderson

      Emma: I think I merely ignored all the propaganda. The USA Surgeon General who was the first to promote the dangers of smoking in the early 1960's stated categorically that the danger applied only to those who smoked 40 or more cigarettes per day and that shifting to cigars or a pipe rendered the danger innocuous. So I took his word for it and blissfully continued smoking 12 tailor-made cigarettes each day and filled in with my pipe. Until my wife said she was not prepared to look after me when I developed emphysema.
      This statement came after the knowledgeable nurse in the cardiac ward filled her ears with all the latest information she had gleaned from anyone who wrote anything against tobacco. So I stopped and chewed a somewhat smelly pipe which gave me the impression that I was smoking an unclean pipe without needing to actually puff.
      Horses for courses probably.

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  3. Isabelle Ellis

    Professor of Rural and Regional Nursing at University of Tasmania

    It is interesting that Ross McKenzie has reported the adult smoking rate in Australia is 15.1%. I think that is misleading in the debate about smoking cessation. There has been no decrease in smoking rates for pregnant Aboriginal women from Western Australia which continues to be around the 50% mark. The ABS report that rural people are also smoking at a rate of between 40 and 50% up to 69 % for women in the Ballarat region. For urban people, quitting has been more a case of the social unacceptability of smoking and the limited places that people can now smoke. Public health campaigns need to focus on a multitude of strategies which may well include NRT but definitely must include reducing the acceptability of smoking for all groups in society.

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  4. Dennis Alexander

    logged in via LinkedIn

    As one who found the patches very useful - it meant I didn't have to avoid bars, coffee shops and other aspects of my life as recommended by the manuals of the time (20 yrs ago), I am not convinced of the validity of the epidemiologicalo method applied - it is self report and compliance with guidelines on NRTs not checked. A mate tried to quit shortly after me. He was cutting patches in half, taking them off to go to the pub and a bunch of other things that pretty much destroyed their efficacy. The patches make you physically sick if you smoke while wearing them. Tampering with patches and other controllable NRTs make it possible to "smoke on demand" - perhaps an implant like the pill. But, compliance with NRT instructions is indicative of readiness and willingness to give up, which may enable the smoker to manage cold turkey. Me, I doubt I'd have made it without the patches.

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  5. Louisa Walsh

    Physiotherapist

    As someone who works in chronic disease self management, and has helped people to quit smoking, I believe that having a range of options available is better than a 'one size fits all' view of any sort of healthy behaviour change. This give people a choice of strategies when deciding on the their quit attempt, and can help with confidence in making an attempt in the first place.

    I also think that the contention that subsidised quit medications and NRT threaten the funding of other public health strategies is a straw man argument - we have seen both approaches coexist in Australia for many years, with NRT not detracting from public health strategies such as plain packaging and tax increases.

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  6. Peter Andrew Smith

    Retired

    As a very heavy smoker who has entirely replaced smoking cigarrettes with use of a nicotine inhaler for the past six years I am happy with the change: no damage to the health of those around me; nicotine available to me indoors and out; less damage to my lungs; etc. I am, however, not aware of any rigorous studies that have considered increasing the uptake of alternative nicotine delivery methods as a goal in its own right.

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  7. Theo van den Berg

    IT consultant and trainee farmer

    Cost of smoking is 31.4 billion in a country with 22 milion people ??? And 19 billion of that is intangible cost i.e. made up as we feel like it. Like when dying 10 years premature, society looses 10 years of my output ??? Get real. And we have to be so politically correct calling a branch a stick, but discrimination against smokers is OK, let's call the lynching party ! And btw, a study in England showed that their cost was 2 billion and that the government collected an extra 7 billion in taxes.

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  8. Sue Stevenson

    Writer

    I think maybe NRT can get you a little way along the road to gaining some distance from your beliefs around smoking. But I used it twice in two attempts, and it was only the third attempt going cold turkey using Alan Carr's The Only Way to Quit Smoking Permanently that stuck. I've been a non-smoker now for about 13 years and it's very rarely that I miss it :)

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  9. Michel Syna Rahme

    logged in via email @hotmail.com

    I do not know much about hypnosis, but just yesterday a friend of mine was talking about how her mother had hypnosis therapy and hasn't smoked for 20 years. Can you please inform us on the credibility of hypnosis therapy? Is it a very effective placebo? Is it effective on only some tyres of people? Are there risks involved in hypnosis therapy?

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  10. Seán McNally

    Market and Social Researcher at eris strategy

    The reason for the debate is that the real world of smoking is neither a tumour that can be cut-out nor an illness which we manage. Sadly it involves people, who – generally - like doing what they do and don’t suffer obvious consequences on a daily basis.

    With vastly more people quitting by cold turkey, more people will naturally have quit without an aid, unless they either the quitting aids are vastly better or going cold turkey is vastly worse.

    Another issue with studies in quit smoking…

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  11. Sue Ieraci

    Public hospital clinician

    The fervour and ideology around quitting smoking seems to be almost as strong as the discussion around diet and weight loss.

    It comes down to this: not all humans are the same, and not all strategies work for everyone.

    I'm not aware of any body of addiction researchers saying that only one method should be used. There are varying bodies of evidence around different methods, and also horses for courses.

    We should resist the temptation to form two camps on everything: harm reduction vs outlawing, balance vs no carbs, fructose is poison, cold turkey is the only way to go....

    What we need is a hierarchy of intervention methods, with their associated evidence and the types of people and habits they are shown to work best for. Where evidence is still developing, it gets added incrementally. It's likely this knowledge already exists in the quit-smoking community. I don't hear anyone saying "it's substitution or nothing" - just as nobody should say "it's cold-turkey or nothing".

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  12. Stuart Eley

    logged in via email @gmail.com

    Does it really confirm what you've said it does?

    "confirms what we’ve long suspected about nicotine replacement therapy (NRT): smokers don’t need to resort to these pharmaceuticals to quit"

    What about the different person that chooses help vs cold turkey? Peoples mindset changes a lot towards smoking over time and throughout quit attempts. Assuming every person has the same mindset towards smoking surely can't work.

    By saying that NRT is as effective as cold turkey means that for people who select NRT they are as likely to quit as someone who chooses cold turkey. This is not the same as saying every person will have the same result whether they choose cold turkey or NRT.

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  13. Scott Baillie

    Software Developer

    I am giving up right now.

    I dont know if medication helps or not but I dont plan to use any.
    I gave up once before for 12 months and I plan to use the same technique as I used the first time, but this time I am not going to let myself start again.

    1. Recognise it is going to hurt like hell and there is no easy way around it. Dont look for some sort of comfort to make it easier, just let it hurt.
    2. Dont give it a try and see how it goes, you have to decide first that you are going to complete…

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    1. Emma Anderson

      Artist and Science Junkie

      In reply to Scott Baillie

      Good luck!

      6. Sarcasm is your friend in those stressful moments.
      7. Turn your irritation into humour whenever you can
      8. You've already succeeded, so now you will keep on winning

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    2. Scott Baillie

      Software Developer

      In reply to Scott Baillie

      I just wanted to post a follow up to my previous post regarding , myself giving up smoking. I know it is a bit off topic , because I don't have any information about whether nicotine replacement therapy is valuable or not because I did not use it. Perhaps it is usefull, perhaps it is not, but I can tell you what was worked for me.

      I think cold turkey for a heavy smoker is a very low probability approach. The pain is so bad , just forget it , so many people will fail using this approach. I believe a process of reduction is neccessary to reduce the amount of pain. This strategy has a lot of risk, it is so easy to allow the reduction process to turn into a full relapse.

      I am down to zero cigarettes now and the pain is still there but it is not severe pain anymore and so I know I can make it from here.

      Phew, thank goodness , because I don't want to have to go through that again.

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  14. John R. Polito

    logged in via Facebook

    The question no journalist has yet attempted to answer is, why? Why does NRT clobber placebo inside randomized clinical trials, yet get clobbered just as badly by cold turkey in population level quitting (see Doran 2006)? Although a number of factors, I believe the most telling is that placebo-controlled clinical trials were never blind as claimed, that you cannot hide the onset of withdrawal from from experienced quitters who became experts at recognizing it. The newest blinding assessments suggest that 3 to 4 times as many participants who were randomly assigned to the placebo group can correctly declare their assignment as guess wrong. It is my belief that years or decades spent toying with replacement nicotine has needlessly cost millions of smokers their lives. The bottom line is that the brain cannot adjust to functioning without nicotine while it continues to arrive.

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