Comprehensive tobacco control legislation has led to an historically low daily smoking rate of 12.8% among Australians aged 14 years or older. Yet smoking is the country’s leading preventable cause of early deaths, taking around 15,000 lives each year.
Getting smokers to quit, therefore, remains a critical public health challenge. Around 85% of Australians visit a general practitioner each year and these appointments represent important opportunities for GPs to explain the health risks of smoking and discuss strategies to quit.
To assist GPs in providing advice about smoking, the Royal Australian College of General Practitioners (RACGP), the professional body for GPs, published Supporting smoking cessation: a guide for health professionals in 2011.
Providing “practical, succinct and evidence-based” advice on cessation is clearly a sound idea, but there is a significant problem with the advice itself. The guidelines focus on pharmaceutical intervention, in the form of nicotine replacement therapy patches, gum or spray, or medication such as buproprion (Zyban) or varenicline (Chantix, Champix). This suggests that successful cessation requires medication of some sort.
This preoccupation with pharmaceutically assisted quitting ignores or dismisses the value of unassisted quitting or going “cold turkey”. This is the most successful means of quitting by which between two-thirds and three-quarters of former smokers stopped smoking. Unassisted quitting is noted in the guidelines but, at best, as a matter of patient choice rather than an option to be encouraged.
There are two key issues that seemingly contribute to this situation. First, evidence cited in support of nicotine-replacement therapy and medications overwhelmingly relies on impressive cessation rates reported by randomised controlled trials. Such outcomes, however, are not replicated in “real world” settings. As professor of public health Simon Chapman recently explained on The Conversation:
- clinical trials exclude many people in vulnerable groups who might buy nicotine replacements
- smokers can guess if they’ve been allocated to the placebo or control arm of the trial
- participants are often paid for their participation and receive the drugs for free
- staff check in with participants regularly and encourage them to stay in the study.
A second concern is that 70% of studies cited in the guidelines that recommended the use of pharmacotherapy reported receiving funding from, and/or that researchers were otherwise supported by, one or more pharmaceutical manufacturers of cessation medication.
Industry funding of research raises concerns around conflict of interest, a situation in which professional judgement concerning a primary interest can be unduly influenced by a secondary interest, either financial or non-financial. Conflicts of interest among industry-funded researchers threaten the integrity of scientific investigations and may affect the quality of recommendations in guidelines.
Further potential for conflict of interest exists among members of the Content Advisory Group (CAG), the authors of the guidelines, as we recently outlined in the journal Public Health Ethics.
Statements of competing interest in the guidelines state that three of the eight CAG members, including the chair, had links with pharmaceutical companies that manufacture smoking cessation products: Pfizer and GlaxoSmithKline.
According to the disclosures outlined in the guidelines, the chair:
provided expert advice on smoking cessation education programs to Pfizer Pty Ltd and GlaxoSmithKline Australia Pty Ltd and has received support to attend smoking cessation conferences.
A second member:
provided smoking cessation advice and training at meetings supported by Pfizer Pty Ltd and is a member of the varenicline advisory board for Pfizer Pty Ltd.
A third member:
received honoraria from Pfizer Pty Ltd for contribution to the varenicline advisory board and for CME lectures at meetings supported by Pfizer Pty Ltd.
Another CAG member has historical links. A 2002 paper declares he was:
a member of a Smoking Cessation Consortium supported by GSK. He is in receipt of untied educational grants from that consortium and has undertaken small consultancies for both GSK and Pharmacia related to promotion of smoking cessation.
And one of the two external reviewers also received industry funding, a recent study declaring he:
received honorariums for teaching, consulting and travel from Pfizer, GlaxoSmithKline, and Johnson and Johnson Pacific.
Why does this matter?
The RACGP recommendations have important implications for quitting strategies adopted by GPs, other health professionals and for the general public who increasingly turn to the internet for medical and health advice.
The RAGCP focus on pharmacotherapy reflects much of the current thinking on quitting smoking in Australia, including the federal government’s own quit campaign.
The Cancer Council Australia, the Heart Foundation, the Australian Council on Smoking and Health, and Quit Victoria all lobbied the Pharmaceutical Benefits Advisory Committee to provide subsidised nicotine replacement therapy to all smokers in 2010 at a cost of roughly A$9m a year.
This has contributed to inadequate research into unassisted cessation, and to policy that either fails to acknowledge the historic effectiveness of unassisted quitting or actively discourages unaided cessation.
Since our analysis was submitted for publication, the RACGP issued a 2014 review of the guidelines that includes new data on smoking rates, and cites further studies in support of pharmacotherapy. The position on unassisted quitting remains unchanged, however, and the key message of the updated guidelines is that:
Pharmacotherapy should be recommended to all dependent smokers who express an interest in quitting, except where contraindicated.
The information that should be delivered by GPs to patients wishing to quit is that:
- cessation is frequently a prolonged process of which unsuccessful attempts are a normal part
- nicotine replacement therapy and other pharmacotherapy may help many smokers but are certainly not necessary for quitting
- unassisted cessation is the method followed by the majority of successful ex-smokers.
Rather than a balanced discussion of available strategies for smoking cessation, the guidelines disregard the historical reality that the large majority of existing former smokers quit unassisted and instead, promote pharmacotherapy as the default for all smokers who wish to stop.