Patrick Basham: The DoH is wrong about cessation

Patrick BashamI’m very disappointed in the section on cessation contained within the UK Department of Health’s new tobacco control strategy. There are several problems with the DoH’s ideas on cessation (and I’ll have more to say about them in future posts), but one of the most significant is its claims about how to quit smoking most successfully.

The strategy document says, “Those who are most successful in quitting use a combination of behavioural and medicinal support.” (p. 11) The only support for this rather extraordinary assertion is an unpublished  report by West entitled, “The smoking pipe: a model of inflow and outflow of smokers in England.” But this source, which is a single page spreadsheet, provides little support for the claim about cessation. More troubling is that the DoH’s claim about the best way to quit smoking fails the most basic test of evidence-based medicine: it is contradicted by much of the published literature.

Lee et al (“Factors associated with successful smoking cessation in the United States,” American Journal of Public Health 2007), using data from the National Health Interview Survey 2000,  report that 76% of successful quitters (for 7-24 months) stopped at once or went cold turkey (without assistance), as compared with 12% who used nicotine patches or gum. Ferguson et al (“Unplanned quit attempts – results from a US sample of smokers and ex-smokers“, Nicotine and Tobacco Research 2009) found that most of those who quit smoking without planning didn’t use either behavioural or medicinal support, and, most crucially, these unplanned attempts to stop were twice as successful as planned attempts. In fact, even in studies where smokers were provided continuous pharmaceutical interventions (e.g. use of a nicotine patch for six months), Schnoll et al (“Effectiveness of extended-duration transdermal nicotine therapy,” Annals of Internal Medicine 2010) found the one year abstinence rate was only 0.8% of the sample. This compares with unaided quit attempts that yield one year abstinence rates of between 3 and 11%. (Gritz et al “Unaided smoking cessation: great American smokeout and New Year’s Day quitters,” Journal of Psychosocial Oncology 1989).

Finally, it is difficult to reconcile the DoH’s use of West to support its claims about how to stop smoking successfully given West’s own research published in the BMJ. West and Sohal, (“Catastrophic pathways to smoking cessation: findings from national survey,” British Medical Journal 2006) in a survey of English smokers and ex-smokers, report that “a substantial proportion of attempts to stop smoking are made without any previous planning and, surprisingly, that unplanned quit attempts have a greater chance of succeeding.”

Why is any of this surprising, particularly given the consistently dismal record of long term success from pharmaceutically-assisted smoking cessation? As the American Cancer Society observed before the incursion of Big Pharma into the nicotine business, “Over 90% of the estimated 37 million people who have stopped smoking in this country…have done so unaided.” (Amercian Cancer Society Cancer facts and figures 1986)

Despite the DoH and the pharmaceutical industry’s promotion of pharmaceutically-aided cessation, the evidence suggests that unassisted cessation, not behavioural and medicinal support, is the method used most often by those who quit smoking successfully. Perhaps, the only people who find this surprising or dismaying are those in the pharma-nicotine industry.

Both physicians and their patients have an unqualified right to expect that the DoH provide scientifically accurate and objective information about smoking and tobacco control policy. The DoH has failed both the profession and the public in its claims about smoking cessation.

Patrick Basham is author of “Butt Out! How Philip Morris Burned Ted Kennedy, the FDA & the Anti-Tobacco Movement” and is coauthor of the bestselling “Diet Nation.” He has taught tobacco regulation and other health policy courses at Johns Hopkins University and has spoken on tobacco policy at universities and conferences around the world. Dr Basham is founding director of the Democracy Institute and is a Cato Institute adjunct scholar.

  • Dave Atherton

    The two most successful ways of giving up smoking are E-Cigarettes, 45% and the Allen Carr The Easy Way To Give Up Smoking book and clinics, 53%. Although I am aware of only one study on E-Cigarettes.

    “Out of 349 participants took part in the study, a staggering amount of 45% have stopped smoking in the time frame of 8 weeks with the E-Cigarettes.” (1)

    On Allen Carr I’ll let Deborah Arnott of ASH UK to say how effective it is.

    “In November of last year (2007), Deborah Arnott, Director of ASH claimed that specific success rates quoted by Allen Carr Easyway were “plucked out of the air” and “basically made up.” She made these comments whilst on the BBC Radio 4 “PM” programme during a piece concerning the death of Allen Carr, founder of Allen Carr’s Easyway organisation.

    Deborah Arnott’s comments referred to two independent studies conducted by eminent experts in the field of smoking cessation which had already been published in peer reviewed journals indicating a 53% success rate for Allen Carr’s Easyway to Stop Smoking Clinics after 12 months.
    Following a complaint by Allen Carr’s Easyway International, Deborah Arnott and ASH now acknowledge that it was wrong for Ms Arnott to have made the comments relating to the 53% success rate and have issued an unreserved apology. ASH has agreed to pay the legal costs incurred by Allen Carr’s Easyway. (2)

    1. http://www.cloud9smoking.com/study_shows-_ecigarette_the_best_quit_smoking_product.html

    2.
    http://allencarr.com/central/article/133/ash-apologise-to-allen-carrs-easyway.

  • Commons

    Patrick Basham is ‘very disappointed’ about the DoH’s strategy; I’m sure the DoH will get over it given the weakness of the criticism and research presented here.

    “More troubling is that the DoH’s claim about the best way to quit smoking fails the most basic test of evidence-based medicine: it is contradicted by much of the published literature.”

    Wait… what? Systematic reviews of the best quality randomised controlled trials show that behavioural support (http://www2.cochrane.org/reviews/en/ab001292.html), and pharmaceutical aids (http://www2.cochrane.org/reviews/en/ab000146.html & http://www2.cochrane.org/reviews/en/ab006103.html) are more effective than placebo and no intervention in helping smokers stop.

    ‘Most commonly used method’ is different from ‘most effective method’.

    Followed up a by-the-numbers swipe at evil big pharma. Not an inspiring start to a healthcare blog.

  • Simon Chapman

    Patrick, Patrick … that’s not very polite to go running the very same argument as Ross Mackenzie and I did in PLoS Medicine in February this year, using several of the very same key references we did, but not acknowledging our paper, now opened over 3600 times on the open-access PLoS Med site
    http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000216 Google “unassisted cessation” and the paper is hard to avoid.

    Commons, you would do well to read our paper. There are several important differences between RCTs and real-world research findings on pharmaceutical aids that should give major pause to messages about success rates. The undeniable message is that unassisted cessation is, and always has been, quite easily the method used by most ex-smokers to quit smoking. Much as it pains me to agree about anything with the likes of Patrick Basham, we seem to agree on this.

  • Rollo Tommasi

    I share Commons’ well-made views about Patrick Basham confusing frequency with effectiveness, and his apparent focus on dissing the pharmaceutical industry over identifying and pursuing the most effective approaches for would-be quitters. He lazily equates NHS support services with pharmaceutical aids alone, ignoring the availability and effectiveness of one-to-one and group support opportunities.

    Basham strangely sees unplanned quit attempts as contradicting evidence about the effectiveness of supported methods of cessation. In fact, the two are not necessarily contradictory – nor should they be. In fact, articles which Basham himself cites make this point clear (it’s just that he chooses not to comment on these….). As Ferguson et al state “methods of making treatment available to assist unplanned quitting should be considered.” There is no reason why NHS support services cannot be offered and tailored for people who have already begun a quit attempt.

    While Lee et al conclude that quit attempts are more likely to succeed when smoking is banned in the home, that is a message that many quitters are more likely to learn from NHS support staff than discover for themselves.

    Must try harder, Mr Basham.

  • In July 2009 Freedom2Choose UK released the news, working with hypnotherapist Chris Holmes, reveals that the continued use of the Department of Health’s claim “you are up to four times more likely to quit with NHS help” has no evidential basis. Freedom2Choose can show that the Department of Health routinely uses misleading statements to promote Nicotine Replacement Therapy (NRT) products as its preferred method of treatment for smoking cessation. This promotion is a very costly exercise, at a time of imminent cutbacks to public services.

    Belinda Cunnison, of pro-choice group Freedom2Choose, investigated the common claim that you are “four times more likely to quit with NHS”, which is used in most promotional materials for NRT products, and frequently in press releases on the subject of smoking cessation. “I traced this claim to a Department of Health web page,(1) which also claimed a 15 per cent
    success rate at 12 months for NRT. The evidence that was supposed to demonstrate this 15 per cent success rate and the ‘four times more likely to quit’ phenomenon was not listed in the footnotes, so I wrote to the Department to ask for it.”

    It took over three months to get the information. The following reports were made available by Cameron Gordon of the Department of Health in relation to smoking cessation studies:

    • The Ferguson Health Inequalities Reduction Paper(2)
    • The Evaluation Report(3)
    • The Shiffman Report(4)
    • The Cochrane Reviews(5)
    • The Hughes Report(6)
    • The Borland Report(7)

    The documents revealed neither a 15 per cent quit rate at 12 months, nor any evidence that quitting with the NHS is four times more effective than willpower alone. The Borland Report recorded a 12-month success rate of 6.5 per cent (higher rates were achieved only in the smaller scale studies), whereas the largest study done on quitting using willpower alone achieved a rate of around 6 per cent.

    “On the government’s own evidence, the claim ‘up to four times more likely to quit with the NHS’ is completely untrue. How can this claim be justified?” continues Belinda Cunnison. “The use of NHS treatments makes almost no difference at all to quitting success. A recent study published in the British Medical Journal(8) has also documented the long-term success rate of NRT at a mere 1.6 per cent. The whole exercise is futile as well as being enormously expensive.”

    Freedom2Choose also has evidence that General Practitioners are given payments for patients who set a quit date, and an additional payment for patients who remain quit at four weeks. The payments are listed in NHS Warwickshire’s board report, March 2009.(9) This reflects the urgency of smoking cessation on the Trust’s list of priorities – an unfortunate choice of priority since patients seem just as good at giving up smoking under their own volition as they are with NHS help.

    “At a time when we need to economise, particularly in the Health Service, why is our Government pumping tax-payers’ money into a failed product and using misleading claims to the service user?” questions Belinda Cunnison. “Will-power alone has a comparable success rate for those who choose to give up smoking. This is a complete waste of our resources.”

    Author and hypnotherapist Chris Holmes(10) agrees and states, “We are exposing a systematic and deliberate policy to seriously mislead the public over the true effectiveness of these services. The actual extent of long term failure was being quietly covered up – which we now know from the Borland report is 94 per cent failure at 12 months – whilst four-week results were shamelessly promoted, even including published ‘success rates’ as high as 90 per cent. Since they knew that to be the exact opposite of the real outcomes, this is a fraudulent misappropriation of hundreds of millions of pounds of taxpayers’ money. NRT simply doesn’t work.”

  • Surely the whole point of this piece is to question the effectiveness of the NHS quit methods offered (which don’t include hypnosis or the Allen Carr method last time I looked) vis-a-vis cold turkey. If it takes the NHS advice that quitters quit more easily in a smoke-free environment to make patches and other medicinal aids work, the effectiveness of such aids must come into question.

  • Taxpayer

    I am repeating this post as it was removed earlier.

    The public have a right to know what is going on in the Tobacco

    Control Movement.

    APPENDIX 2 Page 7(h)
    ” GPs and Pharmacies are reimbursed for service delivery (inflation still to be applied for 09-10):
    £10.50 for each client setting a quit date.
    £40 for each client still quit at 4-week follow-up
    £10.50 for each client not quit at 4-week follow-up. No additional payment for those not followed up at 4 weeks.
    Pharmacies only – £3 per supply of NRT. ”
    http://www.warwickshire.nhs.uk/trustboardenclosures/march09/Enc%2016%20Tobacco%20Control%20and%20Smoking%20Cessation%20Board%20Report%20-%20March%202009.pdf

  • Wiel Maessen

    A study by Reuven Dar and Jean-Francois Etter (Journal of Consulting and Clinical Psychology, 2005, Vol. 73, No. 2, 350–353) shows that the NRT placebo studies, that are commonly performed by the manufacturers, show two major errors: “blindness failure” (smokers may be able to distinguish between nicotine and placebo quite quickly, and this ability to distinguish the two is far greater than by chance) and “blindness bias” (smokers’ judgments about whether they have received nicotine or placebo may be related to the study outcomes: namely, smoking cessation or reduction in cigarette consumption).
    The study shows that, if these errors are controlled for, the positive effect of NRT treatment equals zero.
    According to John Polito, on http://whyquit.com/pr/031207.html, in these studies, placebo users are erroneously compared with cold turkey stoppers.
    He also reports that ‘Surveys from California (2002), Minnesota (2002), Quebec (2004), London (2003), Maryland (2005), UK NHS (2006) and Australia (2006) all report no long-term statistical advantage for quitters using pharmaceutical quitting aids over cold turkey quitters. In fact, in the Australian study, among patients of 1,000 family practice physicians, cold turkey was twice as effective as NRT or bupropion (Zyban/Wellbutrin)’.