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.
What is left out here is followup time.
Like diets, most smoking cessation programs work in the short run — none in the long run (a year or more).
Nicotine addiction is particularly long lived; it takes at least a year to reverse all of he physiological affects of addiction, so short term results are meaningless.
Common phrase: “I know I can quit — I’ve done it a hundred times.”
A quick reading of the PLoS article (a review; not original research) showed no mention of followup times, so it is not clear that the question of long term cessation is addressed.
Mr. Scott, thank you for this article. Also thanks to the authors of the PLoS article. The American Cancer Society and BigPharma make it sound like quitters need their help, when in fact we pay dearly for them to keep their jobs.
After a couple weeks in a smoking cessation group, I asked how many of the people in the class were on drugs. Only three of about twenty were doing it drug free (Pfizer collects on every Chantix prescription, do they not?)
Just an anecdote:
I started smoking at age 15 because my new stepbrother, 16 and the possessor of the key to an adolescent male’s fondest fantasies in 1959 – a car – was a smoker. I wanted to be cool, like him…
Smoked for a few years – a pack a day, more or less – went off to college, and quit for a full year (my junior year). Seemed easy at the time, and I have no idea why I started again, but I did.
Smoked for 26 more consecutive years, gradually increasing from 1 to 2 packs a day. By 1990, as a rational human, I couldn’t convince myself that it was somehow good for my health. Got into an employer-sponsored “Quit smoking” program.
Turned out to be a control issue for me, though by 1990 economics was playing a role, too. I was spending $60 a month on cigarettes, and as a newly-divorced guy, I had much better uses for that money. We were scheduled to quit on February 10, 1990, but I ran out of cigarettes a week before, on a Friday night when it was miserable outside, and decided I didn’t want to go out in the weather for something I didn’t really want to continue anyway. I also didn’t like the idea of someone else telling me it was time to quit.
So I quit a week ahead of schedule, on February 3, 1990, cold turkey. It was NOT a fun weekend – I spent a lot of time pacing through the rooms of my little house – but I wanted to be in charge, so I refused to give in. Haven’t had a cigarette since, or a pipe, or a cigar, or….
A good friend who continued to smoke helped when I went back to work by going to the OTHER employee lounge to smoke for a couple months, but after a couple months, I was OK around smokers as long as they didn’t blow it in my face. I didn’t find it appealing – it was annoying, and irritating to my nose and throat.
Moved to Colorado, where I took up walking on a daily basis, and hiking in high country during the summer. Have since walked many thousands of miles at 3 and 4 miles a day, and hiked about 750 miles at 9,000 feet or higher over the course of several summers before moving to Minnesota last summer, where the daily constitutional continues.
Signed up and took part in a cancer research project through the University of Colorado, and chest x-rays confirm that, at least as of last year, I don’t have anything respiratory that shows up on an x-ray.
This is simply to support the notion that various aids from pharmaceutical companies are not necessarily required. Just willpower.
What finally helped me to quit after many tries was a visit to a hypnotist whose positive messages were stronger, when combined with my firm decision to quit, than the desire for “just one.”
Part of the cure included literature saying how quickly my blood oxygen would return to normal, how soon my chance of a heart attack was no more than a non-smokers, etc., to read every night.
The really effective part, though, were the messages placed in my mind while I was hypnotized.
“I feel so good” irrationally overrode the worst withdrawal symptoms. The message “If I don’t have a cigarette, the craving will go away within 10 minutes. If I do have one, the craving will come back sooner and stronger.” Plus the instruction to look into the mirror several times a day, smile and say, “I’m SO proud of you.”
I imagine these are things people could do for themselves if they know about them, but the hypnotist was a marvelous help .
I’ve emailed Dr. Chapman for clarification on his criterion for ‘permanently quitting smoking’.