Of all the interventions at our disposal in preventive medicine, there's likely no greater opportunity for reducing disease than for a physician to encourage a patient to quit smoking.

After his physical last weekend, we learned that the president is attempting to break his occasional smoking habit with nicotine replacement therapy. NRT methods include nicotine gum, lozenges, sprays and a transdermal patch, but for those wanting to head to the drug store to kick their habit, such smoking cessation drugs as Zyban (a repackaging of the antidepressant Wellbutrin) and Chantix have become available in the last few years as well. 

Some of these methods carry side effects — Chantix and Zyban have been found to make some users overwhelmed with the urge to take their own life, leading the FDA to require Black Box warning labels. (For a harrowing, first-person account on what this actually feels like, see this article from New York magazine in 2008.) Ironically, the drug's potential for self-harm would appear to make it less strange that researchers are now wondering whether it, too, can function as an antidepressant. Unfortunately, when it comes to proving its worth in the risk-benefit equation, all a smoking cessation drug has to do is beat out the Grim Reaper; few side effects associated with drug-induced efforts to quit smoking appear capable of exceeding the risks of smoking itself. 

With so much attention given to assisted means of quitting smoking, it comes as a surprise to learn that the vast majority of those who do quit do so with no help at all. According to a recent article in PLoS Medicine, "The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences," "two thirds to three quarters of ex smokers stop unaided." There is a glass half full/empty scenario at work here. According to the American Cancer Society, only 7 percent of smokers can quit without help. Yet the vast majority of those who do quit, according to the PLoS study, did so on their own. If we only look at all those who haven't quit, we might assume smokers should be directed to the pharmacy for help. But if we look at the millions of smokers who do quit, it seems fair to ask why there aren't more billboards saying, "Most People Quit All on Their Own -- You Can, Too." (Such billboards may indeed be out there.)

According to the authors, a pair of researchers from the University of Sydney, our attention is directed towards assisted quitting because "most published papers of smoking cessation interventions are studies or reviews of assisted cessation." Money, of course, plays a role in this bias: "Many assisted cessation studies," the authors write, "but few if any unassisted cessation studies, are funded by pharmaceutical companies manufacturing cessation products." But the paper is a fascinating read for reasons that go beyond the now well-understood problems created by private money in medicine. It faults the usual suspects, but also an epistemological issue --  our preference for the clarity provided by discrete interventions. Our scientific tradition is such that we have better use for a study of a discrete intervention with a commercial product than we do for studies "that focus on distal, complex, and interactive influences that coalesce across a smoker's lifetime to end in cessation. Specific cessation interventions are also more easily studied than the dynamics and determinants of cessation in populations." 

Indeed, the problems with our fixation on products rather than processes cuts to the heart of our economic systems.

As the authors write, "In 1975, Renaud wrote of the fundamental tendency of capitalism to “transform health needs into commodities ..." As such, "the burgeoning commodification of cessation by manufacturers of both effective and ineffective  drugs seems to have induced a kind of professional amnesia in tobacco control circles about the millions who quit in the decades before the dominance of the contemporary smoking cessation discourse by pharmacotherapy."

Freelancer Paul Scott of Rochester writes frequently about health and fitness for various media. Susan Perry will return Monday.