Ross MacKenzie, Macquarie University
A study published in the latest edition of the journal Tobacco Control confirms what we’ve long suspected about nicotine replacement therapy (NRT): smokers don’t need to resort to these pharmaceuticals to quit.
Researchers at the Harvard School of Public Health and the University of Massachusetts analysed relapse rates among 787 Massachusetts smokers who had recently quit, in three waves of interviews between 2002 and 2006. Participants were asked how they quit smoking, if they used NRT and in which form – gum, patch or inhaler. They were also asked to describe the longest period of continuous use of the product and if they received any form of cessation counselling.
Accounting for variation by gender, race, age, education and level of nicotine dependence, the researchers found that people who relapsed into smoking did so at equivalent rates, whether or not they had used NRT to assist in their quit attempt.
The findings add to the growing literature that questions the effectiveness of NRT to help people quit smoking.
What does the evidence say?
Clinical trials have reported that NRT increases the success rate of quitting by 50% to 70% compared to those receiving placebo. But these impressive results have not been replicated in real-world settings. Population-level studies have found no beneficial effect of the use of nicotine replacement therapy.
Selection criteria covering trial participants and the terms of their participation are among the key reasons for the marked difference in findings.
Research shows that unassisted cessation, or cold turkey, remains the most successful method of quitting. Yet questions about the efficacy of NRT often provoke intense debate within the tobacco control community, with clear implications for countries with high smoking rates which are yet to implement comprehensive tobacco-control regulations.
Perceptions of the effectiveness of NRT are also relevant to Australia and other countries that have enacted advanced legislation. Australia’s adult smoking rate is at a historic low of 15.1%, but tobacco consumption remains a leading public health concern. Some 3.3 million adults continue to smoke daily or weekly, and 15,000 Australians die annually from smoking-related diseases. The total social cost to the national economy is estimated to be $31.4 billion.
Tobacco control policy
Despite the growing evidence of the limitations of NRT in “real-world” situations, pharmaceutical patches, inhalers and gums continue to play a key role in smoking cessation policy.
The Quit Victoria website states that smokers “who have the best chance of quitting are those who get some coaching and use quitting medications”; while NSW Health says proper use of NRT products can be “the key to successfully quitting for good.”
The Commonwealth Department of Health and Ageing’s National Tobacco Campaign states that smokers can double the chances of quitting successfully by using cessation medication, but questions the veracity of ex-smokers’ claims to have quit without medication:
Though many people will say that they have quit cold turkey, often they have used medication or advice and support to help them through.
Support for NRT has been translated into government policy, following a submission to the Pharmaceutical Benefits Advisory by Cancer Council Australia, Heart Foundation, Australian Council on Smoking, and Health and Quit Victoria. Nicotine patches have been subsidised on the Pharmaceutical Benefits Scheme as a prescription smoking-cessation aid since 2011, at a cost of $9 million in the first year of subsidisation.
Another promoter of NRT is, of course, the pharmaceutical industry. The 2011 global sales of NRT were worth an estimated US$2.4 billion. In Australia, patches, gum, and other forms of NRT have been available over the counter for years, and the market continues to expand. Sales increased by 7% in 2011 to $174 million, and market analysts predict continuing strong sales, due in part to the growing range of NRT products available in supermarkets.
Time for evidence-based policy
Pharmaceutical cessation products continue to attract support disproportionate to their usefulness. This distracts attention from the reality that the most common method used by most ex-smokers remains unassisted cessation.
Perhaps most importantly, it threatens funding for evidence-based population level interventions – such as tax increases and media campaigns – that have been primarily responsible for the precipitous drop in smoking rates in Australia in recent decades.