Research Article: The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences

Date Published: February 9, 2010

Publisher: Public Library of Science

Author(s): Simon Chapman, Ross MacKenzie

Abstract: Simon Chapman and Ross MacKenzie review the evidence and argue that health promotion messages should emphasize that the most successful method used by most ex-smokers is unassisted cessation.

Partial Text: As with problem drinking, gambling, and narcotics use [1]–[9] population studies show consistently that a large majority of smokers who permanently stop smoking do so without any form of assistance [10]–[15]. In 2003, some 20 years after the introduction of cessation pharmacotherapies, smokers trying to stop unaided in the past year were twice as numerous as those using pharmacotherapies and only 8.8% of US quit attempters used a behavioural treatment [16]. Moreover, despite the pharmaceutical industry’s efforts to promote pharmacologically mediated cessation and numerous clinical trials demonstrating the efficacy of pharmacotherapy, the most common method used by most people who have successfully stopped smoking remains unassisted cessation (cold turkey or reducing before quitting [16],[17]). In 1986, the American Cancer Society reported that: “Over 90% of the estimated 37 million people who have stopped smoking in this country since the Surgeon General’s first report linking smoking to cancer have done so unaided.” [18]. Today, unassisted cessation continues to lead the next most successful method (nicotine replacement therapy [NRT]) by a wide margin [15],[16].

On May 12, 2009, we searched Medline for “smoking cessation,” limiting results to English language original articles, meta-analyses, and reviews published in 2007 and 2008. Of the 885 papers returned, we excluded those that dealt specifically with the effects of cessation on behavioural, cognitive or affective variables, study recruitment research, health economics, and those papers that had a different primary focus, such as smoking-related diseases.

With approximately two-thirds [16] to three-quarters [15] of ex-smokers stopping unaided, our finding that 91.3% of recent intervention studies focused on assisted cessation provides support for the inverse impact law of smoking cessation [26], although further studies are needed to confirm that the bias towards studies on assisted cessation interventions that we discovered is a long-standing one and not peculiar to the years we studied. We believe there are three main synergistic drivers of the research concentration on assisted cessation and its corollary, the neglect of research on the natural history of unassisted smoking cessation. These are: the dominance of interventionism in health science research; the increasing medicalisation and commodification of cessation; and the persistent, erroneous appeal of the “hardening” hypothesis.

Accumulated evidence from clinical trials shows unequivocally that those who use NRT in trials have 50%–70% greater success than those using placebo [28]. But clinical trial conditions typically overstate real world effectiveness because of factors such as trial participants getting free drugs and “Hawthorne” effects caused by the research attention paid to participants [41] and the participants’ desire to please the researchers with whom they interact. Moreover, Mooney et al. [42] found that only 23% of NRT placebo-controlled trials assessed blindness integrity and 71% of these trials found that the participants could detect if they had been assigned to the active agent, a rate significantly above chance.

There has been a long history of criticism of the medicalisation of everyday life [55] to service social control [56] and medical and pharmaceutical industry profits [57]. As Caron et al. note: “the classic drawback of medicalization is its reductionism, which places excessive emphasis on the biological and individual determinants of disease at the expense of a more holistic perspective that emphasizes the social, cultural, and environmental contributions to disease and illness.” [58]. The neurobiology of nicotine dependency is well-established [59], and understanding of its genetics [60] is accelerating. But plainly, with the existence of many millions of unassisted ex-smokers and given the ways that international variations in their distribution reflect social, cultural, and public-health policy variables, smoking cessation in populations is explained by far more than neurobiology and pharmacology.

In any endeavour, whether it be health-related such as weight loss, physical activity or ending narcotics use, or wider achievements such as business success or artistic virtuosity, it would seem reasonable to consider that studying those who had succeeded or excelled might reveal factors that might be valuable to others. Studying the habits, attitudes, routines, and environments of people who succeed where many others fail is commonplace in other fields so why not study unassisted smoking cessation?

The persistence of unassisted cessation as the most common way that most smokers have succeeded in quitting is an unequivocally positive message that, far from being suppressed or ignored, should be openly embraced by primary health care workers and public-health authorities as the front-line, primary “how” message in all clinical encounters and public communication about cessation. Put another way, a failure to emphasise that most smokers have always stopped unaided would be like claiming that most domestic cooks attend cooking classes. Along with motivational “why” messages designed to stimulate cessation attempts, smokers should be repeatedly told that cold turkey and reducing-then-quitting are the methods most commonly used by successful ex-smokers, that more smokers find it unexpectedly easy or moderately difficult than find it very difficult to quit [25], that many successful ex-smokers do not plan their quitting in advance [52]–[54], and that “failures” are a normal part of the natural history of cessation—rehearsals for eventual success. Lessons learned from researching policy tractable, social support, and personal behavioural (“quit tips”) variables associated with successful cessation should be fed into policy and program planning. Talk of unassisted cessation being “the enemy” of evidence-based cessation should be roundly criticised as both incorrect and unhelpful. Unfortunately, the ability of manufacturers to promote their products through advertising is likely to “drown out” the perspective we urge. We suggest, therefore, that public sector communicators should be encouraged to redress the overwhelming dominance of assisted cessation in public awareness, so that some balance can be restored in smokers’ minds regarding the contribution that assisted and unassisted smoking cessation approaches can make to helping them quit smoking.



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