1. What are U.S. health officials smoking?

    NOT PEER REVIEWED Zhu and colleagues' population level findings contribute to a growing body of external real-world evidence supporting the conclusion that the quitting product marketing industry's "double your chances" mantra is false and deceptive, and that smoker reliance upon it is likely responsible for a host of negative consequences, including failure to quit and premature demise.[1]

    Their review of twenty years of National Health Interview Survey data documents how, despite arrival of a host of new quitting products since 1991, the average annual cessation rate has seen little change. The rate has hovered around 4.4%, with the past decade showing a slight decline over the prior decade, dropping to 4.2% from 4.7%.[2]

    The authors give more than 200 randomized quitting product trials a pass in labeling them "rigorous," while noting that clinical and real-world populations and environments differ. While true and less controversial, I submit that we cannot blind quitters with lengthy quitting histories as to the presence or absence of full-blown withdrawal. Placebo assignment awareness among expert quitters occurs within 72 hours of full nicotine cessation. I contend that placebo-controlled efficacy findings reflect expectations not worth, at levels roughly corresponding to study participant quitting experience.[3]

    It is no secret that approved quitting products have failed to prevail over non-medication, non-NRT, unassisted and cold turkey quitters in nearly all population level assessments since 2000.[4] The burning question is why public health officials have not suspended current cessation policy, which in the U.S. continues to make approved quitting product use recommendations mandatory.

    In June 2000, U.S. health officials intentionally turned their backs on the smoker's natural quitting instincts, in officially ending all support of cold turkey quitting. Since then, the U.S. Guideline has stated that, unless medically contraindicated, all quitters should be told to purchase and use approved quitting products.[5]

    Interestingly, a number of the twenty-year time-line ticks inversely correspond to the intensity of quitting product marketing. For example, 1999 to 2001 saw a full percentage point drop. The June 2000 Guideline with its mandatory use recommendation received wide dissemination, with 44,000 copies of the 179 page document distributed by 2002.

    Today, official U.S. Cessation policy is to undermine confidence in natural cessation at every opportunity. According to current policy, smokers should never attempt to abruptly end nicotine stimulation of brain dopamine pathways, but to continue stimulation via replacement nicotine, bupropion or varenicline.

    Imagine being a cold turkey quitter, visiting the government's quit smoking site, and being bombarded 173 times with the message to use "medication" or "medicine." Imagine downloading a copy of "Clearing the Air," the government's leading quitting booklet, and on page 10 under the "Cold Turkey" section being falsely told that "fewer than five percent of smokers can quit this way," that "most smokers have more success with one of the assisted quitting methods discussed below."[6]

    Cold turkey remains the most popular and productive quitting method of all, generating more long-term successful ex-smokers than all other methods combined. I commend the authors for raising the unintended consequence of over-emphasis upon approved products. Imagine the confidence injury to natural cessation inflicted by three decades of cold turkey bashing. Imagine the hopelessness of repeatedly attempting cessation by use of the best science has to offer, and each time falling flat on your face.[7]

    The authors suggest that the obvious solution isn't so much in working to improve interventions but finding ways to induce more attempts. While important, if placebo-controlled trials were fatally flawed, what do we really know about quitting? What would be the outcome of trials pitting those wanting to quit cold turkey against those wanting to use approved products?

    And how difficult or expensive would it be to conduct prospective studies which follow and monitor cessation attempts, methods and outcomes among smoking patients of family practice physicians? How hard would it be to test five to ten minute patient counseling scripts within the treatment setting?

    There has been almost no study of the common threads among successful cold turkey quitters. Could something as simple as a public health campaign which teaches that lapse almost always equals relapse, arm quitters with the most critical survival lesson of all, that one equals all, that one puff would be too many, while thousands never enough? I submit that it could.[8]

    John R. Polito
    Nicotine Cessation Educator


    [1] Polito JR, Are those who quit smoking paying with their lives because of NRT's failure? BMJ 2012; 344:e886.

    [2] Zhu SH, Lee M, Zhuang YL, Gamst A, Wolfson T, Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades? Tob Control. 2012 Mar;21(2):110-8.

    [3] Polito JR, Smoking cessation trials, CMAJ. 2008 Nov 4;179(10):1037-8; author reply 138. Free Full Text

    [4] Polito JR, Are those who quit smoking paying with their lives because of NRT's failure? BMJ. 2012 Feb 7;344:e886. doi: 10.1136/bmj.e886.

    [5] Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, 2008. Full Text PDF

    [6] NIH-Publication No. 11-1647, Clearing the Air, Printed Oct. 2008, Reprinted August 2011. Full Text PDF

    [7] Polito JR, Dying truths about quitting methods,, Nov. 14, 2011. Full Text

    [8] Polito JR, How to quit smoking,, December 18, 2010. Full Text

    Conflict of Interest:

    Pro bono director of an online cold turkey nicotine cessation forum.

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