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Is Unassisted Quitting The Most Successful Method?

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Once again, my Australian tobacco control colleague, Professor Simon Chapman, has courted controversy by publishing another article railing against smoking cessation treatment for smokers and suggesting that the most successful method is unassisted quitting.

I am truly puzzled as to what Professor Chapman is trying to achieve by this and his earlier similar articles, and also by his rationale. For example, he cited a study by Shiffman and colleagues showing that of all the smokers in the US who tried to quit in 2003, two thirds made their quit attempt with no form of assistance, about a third used a smoking cessation medication and under 9% received some kind of behavioral support. Over three quarters of those making unassisted quit attempts had returned to smoking, but that’s not surprising. The point here is that Professor Chapman appears to think we need to draw more attention to recommending unassisted quitting when it has always been and remains by far the most common form of quit attempt. So to me the very data he cites does not support his basic premise that pharmacological treatment has an undue domination of the smoking cessation landscape.

Professor Chapman also seems to be concerned with the fact that despite most smokers who quit doing so without assistance, (albeit a small minority of those attempting to quit unassisted), most research on cessation focuses on forms of assistance! Well knock me down with a feather…..researchers aren’t doing so much research studying people trying to quit the same remarkably unsuccessful ways they’ve been trying for decades, are instead doing research trying to develop more effective methods! Surely Professor Chapman can’t really be surprised by this any more than he’d be surprised that most research on hypertension focuses on interventional treatments rather than on observing whether people’s hypertension just goes away.

Another odd thing is that Professor Chapman acknowledges that, “Accumulated evidence from clinical trials shows unequivocally that those who use NRT (nicotine replacement therapy) in trials have 50%–70% greater success than those using placebo.” But he appears to doubt that this efficacy transfers into the “real world”. Well Im not sure what constitutes his “real world” but there are now plenty of studies showing that NRT increases quit rates versus no NRT outside of clinical trials, whether it be in naturally occurring quit attempts (West & Zhou, 2007)), situations where the NRT was mailed to the public via a quitline (Miller et al, 2005), or among patients attending a smokers clinic for treatment (Steinberg et al, 2006).

But I’m most puzzled about his willingness to ignore the very clear evidence from prospective clinical trials that smoking cessation treatments work, and recommend an emphasis on (demonstrably inferior) unassisted quitting. If one had to cite a single study that makes the point Id probably choose the US Lung Health Study. This study randomly allocated a large cohort of middle-aged smokers to either “usual medical care” or an intensive smoking cessation treatment consisting of nicotine gum and group counseling. 36% of those given treatment were quit a year later, compared with 9% of those not given treatment (who were free to quit “cold turkey”). One of the key results was that when they did the 15 year follow up they found that significantly more people who had been randomized to receive the smoking cessation intervention were still alive, as compared to those who were randomized to “usual medical care”. So if you want proof that intensive smoking cessation treatment saves lives, this is the study that proves it.

There are some things I agree with in Simon Chapman’s article. I agree that no smoker should be discouraged from making an unassisted quit attempt (nor any serious quit attempt). I agree that we may gain useful information from more research on unassisted quit attempts.

But on the question of whether cold turkey is the most successful quitting method he is simply wrong. Most ex-smokers who have quit have quit that way, yes, and most current smokers who continue smoking have already failed that way as well. The evidence is really crystal clear that smoking cessation treatment consisting of counseling and medication is more successful (the Lung Health Study suggests four times more successful) than no treatment.

My question to Simon would be this: If you had a close relative who you loved very much, who smoked 20 cigarettes per day, and had tried to quit a number of times before but never succeeded, and they asked you to recommend what method would give them the best chance of successfully quitting, what would you say?

If your answer to your relative is “cold turkey”, then you truly believe the message of your paper. Personally, Id rather my loved ones had the best chance of avoiding a premature death, and the same goes for people I educate about quitting smoking.

If you want to read Simon Chapman’s article you can find it at:
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000216


If you want to read a previous comment I made about one of Simon Chapman’s other papers, you can find it at (March 4th, 2009):
http://www.healthline.com/blogs/smoking_cessation/2009/03/should-health-care-services-provide.html


If you want to read an earlier summary of the Lung Health Study (October, 29th, 2009) you can find it at:
http://www.healthline.com/blogs/smoking_cessation/2009/10/classic-study-lung-health-study.html

Other studies showing the “real world” effects of NRT are:

Miller N, Frieden TR, Liu SY, Matte TD, Mostashari F, Deitcher DR, Cummings KM, Chang C, Bauer U, Bassett MT. Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation. Lancet. 2005 May 28-Jun 3;365(9474):1849-54.

Steinberg MB, Foulds J, Richardson DL, Burke MV, Shah P. Pharmacotherapy and smoking cessation at a tobacco dependence clinic. Prev Med. 2006 Feb;42(2):114-9.

West R, Zhou X. Is nicotine replacement therapy for smoking cessation effective in the "real world"? Findings from a prospective multinational cohort study.Thorax. 2007 Nov;62(11):998-1002. Epub 2007 Jun 15.

For the record, I have done work that was funded by companies that market smoking cessation medicines. I’ve published research on smoking cessation medicines (including papers reporting poor results for the medicine under study) as well as on studies of non-pharmacological smoking cessation methods. Some of this is mentioned in my profile.
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About the Author


MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.

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