10th Anniversary of Whyquit.com

Last week marked the 10th anniversary of a smoking cessation website called “whyquit.com”. Now those of you who know me, and know that website and its director, Mr John Polito, may wonder why I’m choosing to give it some free publicity. The website is strongly against the use of all pharmacological aids for smoking cessation, and some would argue that it does harm by misinforming smokers about the harms and benefits of these smoking cessation aids. However, although I certainly do agree that the site does misinform about pharmacological aids, it also has a number of positive qualities and presents a different perspective that may appeal to and help some smokers.

The site started 10 years ago primarily to tell the story of a few individuals who were killed very young by smoking caused diseases. The idea was to vividly tell their tragic stories and to inspire others to quit tobacco and so avoid the same. In 2000 Joel Spitzer, an experienced smoking cessation counselor and author joined whyquit and the site took on more of a role of advising smokers how to quit using a very clear philosophy based on the “cold turkey” method.

The site has a large amount of educational material, including free pdf copies of lengthy books by Polito and one by Spitzer. The descriptions of individual cases of tobacco-caused diseases are informative and will inspire some to avoid the same harrowing experience. The site also has a discussion forum called, “Freedom from nicotine.” But once again the fundamentalist opposition to the use of pharmacotherapy aids is evident in the rules for use of “Freedom from nicotine”. The site states that,
“A single-minded program, those applying for posting privileges must have quit all forms of nicotine delivery cold turkey within the past 30 days, without use of any products, pills or procedures, and remained 100% nicotine-free for at least 72 hours. A nicotine-free forum, any nicotine relapse - even one puff, dip or chew - permanently revokes posting privileges.”

This is a rather unusual requirement for people to use a quit smoking discussion site, and it seems rather odd to ban people “permenantly” from using the discussion forum, because they had a puff or chewed a piece of nicotine gum.

The site contains a large number of factual inaccuracies, particularly when referring to research on the use of pharmacotherapy for smoking cessation and the evidence on it. There are too many examples to mention, but just to mention a few:

- the site states that nicotine withdrawal lasts 72 hours. Most studies of nicotine withdrawal symptoms find these to be significantly raised after the first week, and typically not returning to normal levels for 3 weeks.
- The site asserts that in “real life” studies nicotine replacement therapy doesn’t work and “cold turkey” always produces a higher quit rate. An example of a study refuting that claim is provided below (West and Zhou, 2007)
- The site asserts that placebo-controlled trials of pharmacological treatments are all severely flowed because participants can sometime guess better than chance (.e.g. because the medicines work so well at treating nicotine withdrawal that participants can tell what the got, so the study is not perfectly “double blind”). On this point the site is somewhat out on a limb as most scientific research bodies regard the randomized placebo-controlled trial as amongst the best ways to find out if a drug treatment works or not.
- The idea that the results are entirely due to participants’ awareness of whether or not they received the drug also doesn’t bare much scrutiny. For example, in dose-response studies or studies where there is also an “active” comparison, participants are less able to identify what treatment they received, but the higher dose typically does better than the lower dose, and both do better than placebo.
- The site is also highly critical of anyone who has been funded in any way by pharmaceutical companies, and implies that such a conflict of interest almost certainly causes those individuals (including myself) to lose all independent judgement. While I agree that researchers should declare their sources of funding and that readers should weigh that information when reading research reports, the idea that the whole field has been bought and sold to the pharmaceutical industry is blatantly false. It is not at all uncommon for researchers receiving pharma funds to publish studies with disappointing results for the pharma company, including reports of potentially serious side effects.
(e.g. Foulds, J., Stapleton, J., Hayward, M., Russell, M.A.H., Feyerabend, C., Fleming, T., and Costello, J. Transdermal nicotine patches with low- intensity support to aid smoking cessation in outpatients in a general hospital: a placebo-controlled trial. Arch Fam Med 1993; 2: 417-423.
Foulds, J. and Toone, B. A case of nicotine psychosis? Addiction 1995; 90: 435-437).

The reality is that for years academic researchers have been encouraged by our employers to build bridges with private industry in order to make scientific advances, and do so with their eyes open. Most acknowledge our funding as openly as possible without becoming very tedious (e.g. my funding sources are mentioned on my home page on healthline and also on my program website, rather than on every single blog post). Most of us draw the line at funding from the tobacco companies because they have such a clear and consistent history of distorting science and using primarily for PR purposes, and largely because their ultimate purpose is to sell a product that is extremely harmful to health, rather than products designed to improve health.

However, the point here is not to quibble with every single point or inaccuracy on the site. Rather readers should be aware that in among the inspirational stories and plenty of good advice on this site, there is an almost fundamentalist agenda that its just wrong to use medicines to help you quit smoking. If you agree with that, or are prepared to take it with a pinch of salt, then you may find other aspects of this “single minded program” to be helpful.


Here's an example of a recent "real world" study finding that smokers using NRT have a higher quit rate:
- : Thorax. 2007 Nov;62(11):998-1002. Epub 2007 Jun 15.
- Is nicotine replacement therapy for smoking cessation effective in the "real world"? Findings from a prospective multinational cohort study.
- West R, Zhou X.
- University College London, 2-6 Torrington Place, London WC1E 6BT, UK. robert.west@ucl.ac.uk
BACKGROUND: Increasing smoking cessation rates is an important goal in preventing lung cancer and chronic obstructive pulmonary disease. Nicotine replacement therapy (NRT) has been found in clinical trials to improve the chances of success at stopping, but recent cross-sectional survey data have raised doubts as to whether it is effective when used by smokers making quit attempts unsupervised outside clinical trials. Because of biases inherent in cross-sectional surveys, this issue can only be adequately addressed using longitudinal studies. This paper reports the first study of its kind to examine the issue. METHODS: The ATTEMPT cohort is a multinational cohort study with data collection by the internet which recruited smokers of > or = 5 cigarettes per day aged 35-65 years who were intending to stop smoking within the next 3 months. Phase 1 began in spring 2003 and involved 2009 smokers from the USA, UK, Canada and France. Phase 2 involved 3645 smokers and included the same countries plus Spain. Follow-up assessments were carried out every 3 months. 492 smokers who made a quit attempt without formal behavioural support or bupropion in the first 3-month follow-up period were identified from phase 1, 357 of whom were followed up for a further 6 months. The phase 2 sample involved 906 smokers making quit attempts, 732 of whom were followed up. At baseline, demographic characteristics, smoking history and nicotine dependence were assessed. Smokers who made quit attempts were questioned on methods used to aid them. The main outcome measure was self-report of complete abstinence throughout both the 3-month periods following the quit date. RESULTS: 35.6% of smokers followed up in phase 1 and 29.6% of those followed up in phase 2 used NRT. The odds ratios comparing abstinence for 6 months in those using and those not using NRT, adjusting for nicotine dependence, were 3.0 (95% CI 1.2 to 7.5) for the phase 1 sample and 2.1 (95% CI 1.0 to 4.1) for the phase 2 sample. The difference in success rates between those using NRT and those not using it, adjusted for the Fagerstrom test for nicotine dependence (FTND) score, was 6% in the phase 1 sample and 3.7% in the phase 2 sample. The improved odds of success were not explicable in terms of motivation to use some form of aid to cessation or differential loss to follow-up. CONCLUSION: NRT use by smokers making self-initiated quit attempts without formal behavioural support is associated with improved long-ter

Labels: jonathan foulds, NRT, smoking cessation, whyquit.com

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