Throwing the baby out with the bath water

Alain Braillon, ,
, ,

Other Contributors:

February 01, 2012

Throwing the baby out with the bath water

Alain Braillon(a) MD, PhD, Gerard Dubois(b) MD, MPH.

(a) 27 rue Voiture. 80000 Amiens. France (b) Public Health. Amiens University Hospital. France

In an observational study Alpert and colleagues concluded that persons who have quit smoking relapsed at equivalent rates, whether or not they used nicotine replacement therapy (NRT) to help them in their quit attempts and challenged the funding of cessation medication policy.(1)

They failed to discuss the severe methodological limitations of their study which conflicts the evidences from so many randomized controlled trials. These include, to cite a few : a) the recall biases which challenge covariates quality; b) a major bias of selection considering the high percentages of non screened and of lost of follow-up during the three successive rows (see methods); c) the use of cut-points to derive subgroups for covariates which is not appropriate as there is a continuous distribution of the values with no obvious modal values; d) the absence of the measure of the initial quit rates with nicotine replacement therapy (NRT) and others methods; e) the effect of the comprehensive tobacco control policy implemented since 2002, a major confounding variable. Massachusetts now ranks 9th among the 50 states: 16.1% of the adult population (aged 18+ years) are current cigarette smokers.(2)

Finally, as a population study, the Massachusetts program is more convincing. Since 2006, Massachusetts has offered free treatments to help poor residents (Medicaid) stop smoking. When the program started, about 38 percent of poor Massachusetts residents smoked. By 2008, the smoking rate for poor residents had dropped to about 28 percent. This is 30,000 people in two and a half years, or one in six smokers. No changes were observed in those not covered by the plan (3) Tobacco cessation benefit that includes coverage for medications and behavioral treatments can significantly reduce smoking prevalence.(4)

1 Alpert HR, Connolly GN, Biener L. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. Tob Control. 2012. Oneline 10 Jan 2012. doi:10.1136/tobaccocontrol-2011-050129.

2 Centers for disease control and prevention. Smoking & tobacco use. State highlights 2010. Available at Accessed 19 Jan 2012

3 Goodnough A. Massachusetts Antismoking Plan Gets Attention. 2009 Dec 16. The New York Times Available at Accessed 19 Jan 2012

4 Land T, Warner D, Paskowsky M et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS One 2010 18;5(3):e9770.

Conflict of Interest:

Dr Braillon, a senior tenured consultant, was sacked in 2010 from Prof Dubois' unit by the French Department of Health against the advice of the National Statutory Committee. Prof Dubois was sued for libel by the French Tobacconists Union (Abuse of libel laws and a sacking: The gagging of public health experts in France. Tobacco control blog 8 November 2010). Prof Dubois is honorary president of Alliance Contre le Tabac and chairs the Addiction Committee of the National Academy of Medicine. He has received consulting fees from Pfizer.

Conflict of Interest

None declared