Should smokers be advised to cut down as well as to quit? This is the debate captured in our latest Head to Head article, just published on bmj.com. The cost effectiveness body for England and Wales, the National Institute for Health and Care Excellence (NICE), last year changed its guidance to recommend that smokers are advised to cut down rather than simply to quit smoking, as Gareth Iacobucci reported. However, to achieve this NICE also started to recommend licensed nicotine products for long term use as maintenance treatment rather than simply for smoking cessation.
In the debate, the behavioural medicine researchers Paul Aveyard and Nicola Lindson-Hawley at the University of Oxford, say that “people who are cutting down are more likely to make a future quit attempt than people who are not.” They cite physiological evidence that supports their view: “Nicotine addiction leads to neuroadaptation, and cutting down on smoking might reverse some of this, leading to less craving and withdrawal after stopping—the primary drivers of relapse.” They also note that unlicensed nicotine products are making huge gains in popularity: e-cigarettes are “the most commonly used cessation aid in England,” they say.
However, Gerard Hastings and Marisa de Andrade have a different take on the issue. They dispute e-cigarettes’ effectiveness in smoking cessation, urge caution, and suggest that NICE’s revised guidance may give these untested products implicit approval. They present long term use of nicotine products marketed by big tobacco as commercial exploitation of smokers attempting to quit.
Calling for a broader view of smoking than nicotine dependency, they say, “When the only obstacle to progress on preventing the harms of smoking is the user’s dependence, e-cigarettes offer the beguiling prospect of addicted smokers migrating painlessly to safer mechanisms of nicotine delivery.” But without evidence that e-cigarettes work, they conclude, “The tobacco multinationals have leapt enthusiastically into this market; all now have major e-cigarette interests. This is not a consumer movement but the full onslaught of corporate capital in hot pursuit of a profitable opportunity.”
In other news: a recent Personal View by an Australian district medical officer, David Berger, on his experiences of corruption in Indian medicine and healthcare is also stimulating debate. In a rapid response published today, the head of a non-profit hospital in Delhi sympathises with Berger: “Deviance has been normalized to a huge extent,” Abhishek Bhartia says, calling for a systems approach to “address myriad interrelated factors.” He also cites doctors’ low pay among other factors that need to be looked at.
Richard Hurley is deputy magazine editor for The BMJ.