NOT PEER REVIEWED
I note this article in Tobacco Control quotes my two recent articles on the Bhutanese endgame. However, the Tobacco Control article to a certain degree does not catch the spirit of what is going on in Bhutan and what I concluded in my publications. Importation of small amounts of tobacco for personal consumption is legal. Sales are not--they are banned nationwide. Nevertheless, there is a major tobacco black mark...
NOT PEER REVIEWED
I note this article in Tobacco Control quotes my two recent articles on the Bhutanese endgame. However, the Tobacco Control article to a certain degree does not catch the spirit of what is going on in Bhutan and what I concluded in my publications. Importation of small amounts of tobacco for personal consumption is legal. Sales are not--they are banned nationwide. Nevertheless, there is a major tobacco black market and smuggling that bypasses the provision of importation for personal use because the actual demand is much higher than the restricted supply coming in over the border. In other words, the issue of violating prohibition or even quasi-prohibition looms large. There is no discussion in this article of how to specifically solve this major problem particularly in the context of previous failed prohibition or neo-prohibition projects like American alcohol prohibition.
NOT PEER REVIEWED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]
NOT PEER REVIEWED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 www.SmokeFree.gov 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
References:
[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, WhyQuit.com, Nov. 14, 2011. Full Text
[8] Polito JR, How to quit smoking, WhyQuit.com, December 18, 2010. Full Text
Conflict of Interest:
Pro bono director of an online cold turkey nicotine cessation forum.
The volume of attention to our study in the U.S. and international
press is not surprising, considering the widespread promotion of nicotine
replacement products to all smokers in the population, and their growing
inclusion in government subsidized health plans. Prior to addressing
criticisms made by Stapleton and others, we note that their comments
reflect at least one important area of agreement. The fact that no
adva...
The volume of attention to our study in the U.S. and international
press is not surprising, considering the widespread promotion of nicotine
replacement products to all smokers in the population, and their growing
inclusion in government subsidized health plans. Prior to addressing
criticisms made by Stapleton and others, we note that their comments
reflect at least one important area of agreement. The fact that no
advantage for long term abstinence was found for users of nicotine
replacement therapies (NRT) comes as no surprise even to critics of the
study findings underscores general consensus that NRT treatment has not
solved the problem of relapse to smoking.
The argument is that our study ignores initial quit rates and that
improved initial quit rates would be expected to have a long-lasting
effect on population smoking rates. The logic of this argument is that use
of NRT will increase the number of smokers in the population who quit
initially, and even given the same relapse rate as of non-users, NRT would
result in a larger number of long term quitters than would be the case had
none of the smokers used it initially. That hope or expectation was
prominent around the time that the U.S. Food and Drug Administration
permitted NRT to be sold without prescription. Unfortunately, however, the
predicted increases in both rates of quitting and long-term quitters
failed to materialize, (Pierce et al., 2012) even though annual sales of
NRT in the U.S. increased dramatically.
The meta-analyses by Etter et. al., which Stapleton suggests provides
better information than our recent study, is also based on clinical
trials, and subject to limitations for assessing population effectiveness
as discussed in our paper. Further, none of the prospective studies
reviewed in Hughes et. al. found a population effect of over-the-counter
NRT.
The argument has been made that a form of selection bias may have
occurred in which persons more addicted may have been more likely to seek
treatment and also have been more prone to relapse. The likelihood of such
a bias affecting the results was diminished by the study's control for
level of dependence. On the contrary, the counterargument could be made
that persons who made the effort to try and use NRT were actually more
highly motivated to quit and consequently should have been less likely to
relapse, in further support of our study's findings.
Indeed, because of the primary role of motivation in cessation, clinical
trials for NRT tend to be highly selective for subjects who are strongly
motivated to try and quit.
The possibility of recall bias (that people who quit a longer time
ago would find it more difficult to recall whether or not they used NRT)
was addressed in the study by a sensitivity analysis, the results of which
showed consistency of findings based on prior six months, one year, and
two years reported abstinence. The sample size was reasonable for this
study; and, a point missed by Stapleton, was sufficient to detect a
statistically significantly <higher> rate of relapse among formerly
heavy smokers who used NRT without counseling.
Although a major objective of the study was not to assess adherence
to NRT use or reasons for its inappropriate use, the fact that many NRT
users did not continue to use it for the recommended eight weeks raises
more of a question regarding its effectiveness outside of the controlled
trial setting than doubt regarding the findings.
Braillon and Dubois suggested the results might have differed had we
analyzed covariates using alternative forms. We analyzed the data using
categorical as well as ordinal variables for dependence, including a three
-category scale from the Fagerstrom Test of Nicotine Dependence, and four-
category variables representing numbers of packs smoked per day, age as
well as education, respectively. Analyzing these variables as categorical
is common practice. We do not think that the continuous form is
necessarily a better representation than the ordinal form for each of
these variables since the theorized relationships with relapse are not
necessarily linear and monotonic. The results of these analyses with
respect to NRT were qualitatively the same as the original analyses
showing no differences except that use of NRT for at least six weeks
without counseling was associated with higher rates of relapse.
Finally, Beard et. al. reports regarding smokers who "had not smoked
for the last 4 weeks" and no misrepresentation was intended.
We are gratified by the attention that our study has received because
we think it is important to examine the evidence both for and against this
approach to one of the most vexing public health scourges of our time -
tobacco addiction.
Pierce JP, Cummins SE, White MM, Humphrey A, Messer K. Quitlines and
Nicotine Replacement for Smoking Cessation: Do We Need to Change Policy?
Annu Rev Public Health. 2012 Apr 4. [Epub ahead of print]
Etter JF, Stapleton JA. Nicotine replacement therapy for long- term
smoking cessation: a meta-analysis. Tob Control 2006;15:280-5.
Hughes JR, Peters EN, Naud S. Effectiveness of over-the-counter
nicotine replacement therapy: a qualitative review of nonrandomized
trials. Nicotine Tob Res. 2011;13:512-22.
Beard, E., McNeill, A., Aveyard, P., Fidler, J., & West, R.
Association between use of nicotine replacement therapy for harm reduction
and smoking cessation: a prospective study of English smokers. Tobacco
Control, 10.1136/tobaccocontrol-2011-050007 Online 1 December 2011.
(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 qu...
(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
http://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2010/states/massachusetts/index.htm
Accessed 19 Jan 2012
3 Goodnough A. Massachusetts Antismoking Plan Gets Attention. 2009
Dec 16. The New York Times Available at
http://www.nytimes.com/2009/12/17/us/17smoke.html 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.
In their paper claiming to find that NRT is not effective long-term,
Alpert et al [1] misrepresented findings from a paper for which I was
primary author [2], citing it as evidence that other representative
population studies have not found any beneficial effect of the use of NRT
on annual smoking cessation rates. They state 'Beard et al found increased
short-term abstinence only (sic) among persons who had reported using...
In their paper claiming to find that NRT is not effective long-term,
Alpert et al [1] misrepresented findings from a paper for which I was
primary author [2], citing it as evidence that other representative
population studies have not found any beneficial effect of the use of NRT
on annual smoking cessation rates. They state 'Beard et al found increased
short-term abstinence only (sic) among persons who had reported using NRT
six months earlier'. This is misleading given that we only looked at short
-term cessation. The referencing is also erroneous, with our paper
appearing as a sub-paper of Chapman and MacKenzie's [3], labelled 15a and
15 respectively. Our paper has no affiliation with these authors and we do
not argue for the abandonment of clinical treatments for smokers.
1. Alpert, H. R., Connolly, G. N., & Biener, L. A. (2012).
prospective study challenging the effectiveness of population-based
medical intervention for smoking cessation. Tobacco Control,
10.1136/tobaccocontrol-2011-050129 Online 12 January 2012
2. Beard, E., McNeill, A., Aveyard, P., Fidler, J., & West, R.
(in press). Association between use of nicotine replacement therapy for
harm reduction and smoking cessation: a prospective study of English
smokers. Tobacco Control, 10.1136/tobaccocontrol-2011-050007 Online 1
December 2011
3. Chapman, S, & MacKenzie, R. (2010). The global research
neglect of unassisted smoking cessation: causes and consequences. PLoS
Med,7(2), e1000216.
Conflict of Interest:
Emma Beard has received conference funding from Pfizer
Professor Chitta Choudhury
Director, International Centre for Tropical Oral Health, UK
Nitte University Dept of Oral Biology Genomic Studies | Cen Oral Dis
Prev Control, Mangalore, India.
NOT PEER REVIEWED
I refer to the report "How online sales and promotion of snus
contravenes current European Union legislation, published recently in Tob
Control 21 January 2012.
Like Snus, the online trade of Gutkh...
Professor Chitta Choudhury
Director, International Centre for Tropical Oral Health, UK
Nitte University Dept of Oral Biology Genomic Studies | Cen Oral Dis
Prev Control, Mangalore, India.
NOT PEER REVIEWED
I refer to the report "How online sales and promotion of snus
contravenes current European Union legislation, published recently in Tob
Control 21 January 2012.
Like Snus, the online trade of Gutkha (Indian variety of Smokeless
tobacco- ST) is gaining popularity as well as in several outlets in
the UK. If you visit some of the shops in East and north-west London
or in Birmingham, Manchester, Leeds, and Leister (where SE Asian
immigrants are living) you can easily find many shops displaying
various brands of Gutkha sachets. As a member of the National Institute of
Clinical Excellence, (NICE, UK) stakeholders on Smokeless Tobacco control
for SE Asian Migrants , I joined in a meeting and raised the question of
why we can't stop such trade,likewise Snus. But the fact is that there is
no strong legislative support to ban this trade. There is no doubt that online
trade of ST products (not only Snus, also Guthka) is on rise.
Anyway, the results of a database search regarding online sales and
promotion of Snus revealed that online vendors are targeting non-
Swedish EU citizens. Such online trade may also cross more distant borders, reaching Asia, Africa and Gulf countries. Of course, such business is against
the EU regulation. The Snus is banned in the UK and EU countries, but not
the Gutkha. We don't know why Gutkha is not banned in EU. In this context,
I refer one of our discussions published in Tob Control 9 Nov 2010, suggesting that
Snus and quid (eg. Gutkha) consumption is a risk factor not only for the occurrence
of Oral Cancer, but also for development of Metabolic Syndrome
http://tobaccocontrol.bmj.com/content/19/4/297/reply#tobaccocontrol_el_3489
In my opinion, we require a clear-cut and focused directive
of the WHO Framework Convention on Tobacco Control that specifically addresses Snus and Gutkha. If we can not control online trade of Snus, it will be a bad
situation, because the web-based trade crosses the border very quickly, not
only in EU but also other parts of the world. The disturbing fact is that
Sweden is a signatory of the FCTC yet the Swedish Government is getting
revenue from this online Snus trade.
Professor Chitta CHOUDHURY | Nitte University & Int'l Centre of
Tropical Oral Health, UK
Director, Centre for Oral Disease Prevention & Control, NICE
Stakeholder on ST control for SE Asian Migrants in the UK.
The results of the recent study by Alpert et al. were interpreted
incorrectly with respect to the efficacy of nicotine replacement therapy
(NRT).(1) The study only considered relative relapse rates among people
who had already stopped smoking according to whether they had used NRT or
not. This is clearly an inadequate design to address the issue of efficacy
because it ignores the initial quit rates in the two groups. Only...
The results of the recent study by Alpert et al. were interpreted
incorrectly with respect to the efficacy of nicotine replacement therapy
(NRT).(1) The study only considered relative relapse rates among people
who had already stopped smoking according to whether they had used NRT or
not. This is clearly an inadequate design to address the issue of efficacy
because it ignores the initial quit rates in the two groups. Only if the
results had indicated significantly higher relapse among those using NRT
might they have offered evidence against long-term NRT efficacy,
depending, of course, on the initial difference in quit rates (not
measured) and the difference in relapse rates. However, this was not the
case. There was no evidence of differential relapse. Therefore, the
conclusion that these data provide evidence against the effectiveness of
NRT is wrong.
Had the authors considered more thoroughly the literature they would
surely have been enlightened by the meta-analysis review of relapse and
long-term NRT effectiveness published in Tobacco Control.(2) It would have
helped them understand the issues and to draw an appropriate conclusion,
rather than a perverse one. That review included 4792 randomized subjects
(not self-selected as in the new study) followed up for several years and
found the same result as Alpert: the relapse rate did not differ between
those using NRT and others. Consequently, because the initial NRT quit
rate was higher, efficacy remained after a mean follow-up time of 4.3
years (Odds ratio =1.99, 95% C.I. = 1.50 to 2.64). In contrast to the new
study, all the subjects in that review received some form of professional
support, although often minimal. Therefore, the same finding with respect
to relapse in the new population-based study tends, if anything, to
broaden rather than diminish the evidence for long-term NRT effectiveness.
(1) Alpert HR, Connolly GN, Biener L. A prospective study challenging
the effectiveness of population-based medical intervention for smoking
cessation. Tob Control 2012 10.1136/tobaccocontrol-2011-050129 Online 12
January
(2) Etter JF, Stapleton JA. Nicotine replacement therapy for long-
term smoking cessation: a meta-analysis. Tob Control 2006;15(4):280-5.
Conflict of Interest:
John Stapleton has conducted trials of nicotine replacement and other treatments for tobacco dependence supported by the Medical Research Council, the Department of Health and Cancer Research UK. He was formally an adviser on issues of study design and methodology to several manufacturers of smoking cessation medications, including NRT, bupropion and varenicline.
Many of Alpert, Connolly and Biener's population level NRT post-
cessation findings are disturbing and worthy of further and deeper review.
What's most baffling is that any government would invest so much
confidence and so many lives in a product without demanding a shred of
population level evidence as to its worth.
According to this paper, the odds of relapse for a heavily dependent
NRT quitter who had quit le...
Many of Alpert, Connolly and Biener's population level NRT post-
cessation findings are disturbing and worthy of further and deeper review.
What's most baffling is that any government would invest so much
confidence and so many lives in a product without demanding a shred of
population level evidence as to its worth.
According to this paper, the odds of relapse for a heavily dependent
NRT quitter who had quit less than six months were 3.53 times that of a
heavily dependent quitter who quit without NRT or professional help. If
true, that puts a rather hefty dent in NRT's most favored failure
explanation, its selection bias theory.
This finding makes troubling the fact that varenicline
(Chantix/Champix) failed to prevail in long-term point prevalence quitting
over nicotine patch in the only head-to-head clinical trials to date
(Aubin 2008 and Tsukahara 2010).
Alpert and colleagues do not attempt to explain the conflict between
clinical trial and population level NRT findings. But I submit that this
outcome was suggested by the first NRT clinical trial ever, the 1971
nicotine gum study by Ohlin and Westling.
Ohlin and Westling found that counseling and support ("ten visits and
more persuasion") was superior to nicotine gum alone, but that nicotine
gum could defeat placebo gum users. Even then, Ohlin and Westling
documented obvious nicotine gum blinding concerns.
Try to name any other placebo-controlled study area where the
condition sought to be treated (withdrawal) does not exist until
researchers command its onset. Name any other study area where the
placebo group is actually punished within 24 hours by a rising tide of
anxieties.
Have three decades of referring to nicotine as "medicine" and its use
"therapy" undermined natural learning and the quitter's ability to self-
discover the most critical recovery lesson of all, that lapse almost
always equals relapse, that one puff is too many and thousands never
enough?
Nearly all population level quitting method surveys to date have
found NRT less effective long-term than quitting without it. If true, are
taxpayers today paying to reduce the quitter's odds of success? Are we
responsible for undercutting their chances and costing many their lives?
John R. Polito
Nicotine Cessation Educator
Conflict of Interest:
Pro bono director of a cold turkey stop smoking website.
Attending the RCP annual conference in 1999 in London, I remember a
delegate suggesting during a discussion on tobacco control that providing
cheap tobacco could be one way for China to control its population. Though
the suggestion was generally felt to be in poor taste, I am shell shocked
to read the conclusions of this article !
One would imagine that public concern about butt litter would largely
rise with the amount of butt litter that occurs. One would also
reasonably imagine that news articles dealing with the "problem" of butt
litter would similarly rise. If we take those two assumptions as being a
given for the moment, and then look at the statistics uncovered by this
research, we see something very interesting.
One would imagine that public concern about butt litter would largely
rise with the amount of butt litter that occurs. One would also
reasonably imagine that news articles dealing with the "problem" of butt
litter would similarly rise. If we take those two assumptions as being a
given for the moment, and then look at the statistics uncovered by this
research, we see something very interesting.
Using Google's time search feature we are able to search for news
stories/articles in discrete time units. During the period of 10 inclusive
years 1982 to 1991, there were 7 stories: i.e. less than one story per
year. But during the inclusive 8 year period of 2002 to 2009, there were
242 stories, roughly 30 per year. That's over a 3,000% increase in public
perception of and attention to the problem, which would indicate that
there may have been as much as a 3,000% actual increase in the amount of
butt litter between these two comparative periods.
Some of that may have been generated by increased paranoia about
smoke and dislike/hatred of smoking and smokers, but it's likely that a
great deal of it represents an actual and very serious increase in the
problem.
So what changed in our society between those two periods that caused
this problem to undergo such an incredible escalation? It could be that
there are now far more smokers per given area than there were in the
1980s... but tobacco control statistics don't seem to bear that out:
generally they claim a decrease in smokers while habitable/used land areas
in cities/towns/beaches/parks etc have generally increased along with
general population growth during those years. It could be that smokers
are now less conscious of butt littering as a problem, but given the
increase in media attention to the issue this is also unlikely to be a
cause.
The one outstandingly obvious and overwhelming cause of this problem
would seem to be the antismoking movement's insistence upon throwing
smokers out into the streets to smoke rather than allow for provision of
comfortably separated and ventilated indoor options and venues for smokers
and their friends.
If cigarette butt pollution is indeed the true concern here, then
such indoor options should clearly be explored. If however, as indicated
in the abstract, the focus on cigarette butt litter is simply because such
a focus is seen as a way to "justify environmental regulation and policies
that raise the price of tobacco and further denormalise its use." -- a
pure social engineering mechanism -- then such solutions will of course be
ignored.
Which path do you think tobacco control will take?
Michael J. McFadden,
Author of "Dissecting Antismokers' Brains"
Conflict of Interest:
Author of "Dissecting Antismokers' Brains"
Active member of (and sometimes officer in) a number of citizens' Free Choice groups. No compensation involved.
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...
The volume of attention to our study in the U.S. and international press is not surprising, considering the widespread promotion of nicotine replacement products to all smokers in the population, and their growing inclusion in government subsidized health plans. Prior to addressing criticisms made by Stapleton and others, we note that their comments reflect at least one important area of agreement. The fact that no adva...
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 qu...
In their paper claiming to find that NRT is not effective long-term, Alpert et al [1] misrepresented findings from a paper for which I was primary author [2], citing it as evidence that other representative population studies have not found any beneficial effect of the use of NRT on annual smoking cessation rates. They state 'Beard et al found increased short-term abstinence only (sic) among persons who had reported using...
Professor Chitta Choudhury Director, International Centre for Tropical Oral Health, UK
Nitte University Dept of Oral Biology Genomic Studies | Cen Oral Dis Prev Control, Mangalore, India.
NOT PEER REVIEWED I refer to the report "How online sales and promotion of snus contravenes current European Union legislation, published recently in Tob Control 21 January 2012. Like Snus, the online trade of Gutkh...
The results of the recent study by Alpert et al. were interpreted incorrectly with respect to the efficacy of nicotine replacement therapy (NRT).(1) The study only considered relative relapse rates among people who had already stopped smoking according to whether they had used NRT or not. This is clearly an inadequate design to address the issue of efficacy because it ignores the initial quit rates in the two groups. Only...
Many of Alpert, Connolly and Biener's population level NRT post- cessation findings are disturbing and worthy of further and deeper review. What's most baffling is that any government would invest so much confidence and so many lives in a product without demanding a shred of population level evidence as to its worth.
According to this paper, the odds of relapse for a heavily dependent NRT quitter who had quit le...
Attending the RCP annual conference in 1999 in London, I remember a delegate suggesting during a discussion on tobacco control that providing cheap tobacco could be one way for China to control its population. Though the suggestion was generally felt to be in poor taste, I am shell shocked to read the conclusions of this article !
Conflict of Interest:
None declared
One would imagine that public concern about butt litter would largely rise with the amount of butt litter that occurs. One would also reasonably imagine that news articles dealing with the "problem" of butt litter would similarly rise. If we take those two assumptions as being a given for the moment, and then look at the statistics uncovered by this research, we see something very interesting.
Using Google's t...
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