NOT PEER REVIEWED Fotuhi et al concluded in their interesting study of patterns in smokers' cognitive dissonance-reducing beliefs that rationalisations about smoking change systematically with changes in smoking behaviour(1). Moreover, they argue that: i) changes in attitude on quitting are higher for 'functional' beliefs rather than 'risk-minimising' beliefs and ii) if smokers relapse these functional beliefs return to pre-quit levels, iii) that changes in beliefs follow the changes in behaviour (quitting), suggesting that iv) these changes are rationalisations invoked in the service of motivation to reduce cognitive dissonance and that v) smokers are able to reduce dissonance by modifying their beliefs in ways that help to rationalise their continued smoking.

We wish to suggest an alternative understanding. The functional belief items include questions such as "smoking calms you down when you are stressed or upset" and "smoking helps you concentrate better". We propose that these items are not examples of dissonance-reducing attitudes but are representations of smokers' genuine experiences of nicotine withdrawal 'in between' cigarettes or on quitting, i.e. 'stress' and 'poor concentration'(2). In this way they are more a proxy for the physiological states induced by nicotine deprivation rather than attitudes and beliefs per se. Therefore 'risk-minimising beliefs' such as 'the medical evidence that smoking is harmful is exaggerated' and 'you've got to die of something, so why not enjoy yourself and smoke' may more truly represent cognitive dissonance, as they do not overlap with experiences indicating withdrawal symptoms.

A misinterpretation of these withdrawal symptoms by smokers and a commonly held belief that smoking reduces stress will undoubtedly result in the kind of results that the authors report - but should these results really be interpretated as supporting their hypothesis? Once smokers stop smoking, withdrawal symptoms subside over ensuing weeks (3), with 'functional' justifications for smoking naturally receding. They would return when the smoker then recommences to a physiological state of dependency and nicotine deprivation.

The theory of reasoned action holds that attitude changes precede behavioural change (4). The authors conclude that their study shows conversely, for smokers that their changes in attitudes are likely to be a result of their changes in smoking behaviour. This interpretation does not prove causation if these 'cognitive-dissonance' measures are more an indication of the presence of physiological symptoms rather than attitudes and beliefs per se.

We do agree, however, with Fotuhi et al's proposal that public health measures should target smokers' beliefs that smoking reduces stress. This would promote greater understanding about the withdrawal process and link it to why pharmacotherapy can be a useful adjunct to quitting and thereby increase their sense of response and self-efficacy (5).

We have been working in Australia with Indigenous smokers who have a high prevalence of smoking. One of the teaching tools we have developed is a simple visual model to explain to the lay public in the context of a group or personal intervention why smoking increases stress levels, how withdrawal symptoms make smokers more stressed and how nicotine replacement therapy can be efficacious (6).

Resistance to anti-tobacco messages, and cognitive dissonance will most likely continue to plague smokers who do not feel able to quit. Although for Indigenous smokers, knowledge acquisition alone may not be enough to support successful cessation (7), we believe smokers' justifications for smoking may also represent the truth for them of their experiences of withdrawal, and a lack of understanding about nicotine deprivation.

References

1. Fotuhi O, Fong GT, Zanna MP, Borland R, Yong H-H, Cummings KM. Patterns of cognitive dissonance-reducing beliefs among smokers: a longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. January 3, 2012. doi: 10.1136/tobaccocontrol-2011-050139 2. Parrott AC, Garnham NJ, Wesnes K, Pincock C. Cigarette Smoking and Abstinence: Comparative Effects Upon Cognitive Task Performance and Mood State over 24 Hours. Human Psychopharmacology: Clinical and Experimental. 1996;11(5):391-400. 3. Hughes JR. Tobacco withdrawal in self-quitters. J Consult Clin Psychol. 1992;60(5):689-97. 4. Fishbein M, Ajzen, I. Belief, attitude, attention and behaviour: An introduction to theory and research. Reading, MA: Addison-Wesley; 1975. 5. Witte K, Meyer G., Martell, D. Effective health risk messages: a step- by-step guide. Thousand Oaks, CA: Sage Publications; 2001. 6. Baker F, Gould, GS. Blow Away The Smokes DVD: Quit Cafe Scene starts 13.00min. 2011 [4 July 2012]; Available from: http://www.blowawaythesmokes.com.au 7. Gould G, Munn, J, Watters, T, McEwen, A, Clough, A. Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait Islanders: a systematic review and meta-ethnography. Nic Tob Res. 2012;under review

Conflict of Interest:

None declared

I would like to make one correction and some comments on this article's interpretations of our prior review article on hardening (Drug Alcohol Dependence 117:111-17, 2011).

The Cohen et al article cites the prior review as treating "tobacco control policies solely as a driver of quit attempts, with no impact on the ability to maintain abstinence after a quit attempt (p 266)." The article actually stated "tobacco control activities appear to more strongly influence a quit attempt whereas treatment. . . appears to more strongly influence the ability to abstain.(p 112) "

The article also proposes that rather than conduct more research on hardening as the prior review proposed, that we should more fully fund tobacco control interventions(p 265). Since when do research and tobacco control funds compete? Should we stop all lung cancer research as well?

The article also states knowing if hardening occurs "will not have bona fide implications" for tobacco control. The prior review outlined that if hardening was occuring due to the inability to stop due to increased nicotine dependence, this would suggest that a larger and larger group of smokers would be unlikely to quit without treatment. This assertion is based on the evidence that dependent drug users often need more than simple motivation to quit.

The article also states that "insistence that individual smokers are becoming more resistant to quitting and that populations are hardening (note my review never "insisted" this) is reminiscent of victim blaming. (p 266). If anything hardening recognizes that some smokers are unable to quit, not due to lack of motivation, but because they have a significant disorder (nicotine dependence) that can improve with treatment. This is more emphathic than it is victimizing. In fact, "denormalization" (i.e. stigmatization)is much more victim blaming than noting some smokers have a disorder. Would we say promoting antidepressants for those who cannot overcome depression by themselves is "victim blaming" whereas seeing depression as abnormal (i.e. denormalizing) is not?

Finally, many articles on hardening begin by pointing out that we have not really increased quit attempts or cessation success recently in the US (see article by Zhu). In response, many tobacco control advocates say essentially "it's not that the tobacco control actions don't work, it's because they have not been fully implemented." That is a reasonable hypothesis, but it is just a hypothesis. Although some correlational data support it (e.g. see success in CA), the more valid direct experimental tests via the many community trials do not consistently support the hypothesis (e.g. see Cochrane review of community trials).

Conflict of Interest:

I have received grants and consulting fees from several for-profit and non-profit companies that market medication and psychosocial treatments for smoking cessation or engage in tobacco control activities

Zawertailo, Selby and colleagues conclusion that free replacement nicotine (NRT) by mail is effective is deeply disturbing.[1] While the study's free abstract portrays free NRT by mail as a resounding success (21.4% smoking cessation at 6 months versus 11.6% for no-intervention), it neglects mention that under intent-to-treat analysis that there was zero benefit over no-intervention (an average of 8.7 percent 30-day point prevalence at 6 months for both mailed NRT and control).

All evidence presented in the 2008 Guideline Update relied exclusively upon intent-to-treat data. Here, the rates shared in the abstract ignore 2,746 six-month follow-ups where participants were successfully reached by phone. Why? Because they either hung-up or refused interview. It's a number greater than the 2,601 actually interviewed. Do happy, thankful and successful quitters normally hang-up after previously agreeing to follow-up?

A number of recent population studies have found NRT totally ineffective (Ferguson 2005, Doran 2006, Hartman NCI 2006, Pierce 2012, Alpert 2012 and Coleman 2012). The prospect of a billion smoking related deaths before century's end, now is not the time for creative quitting definitions which ignore disappointed or disgruntled participants.

John R. Polito, JD

[1] Zawertailo L, Dragonetti R, Bondy SJ, Victor JC and Selby P, Reach and effectiveness of mailed nicotine replacement therapy for smokers: 6-month outcomes in a naturalistic exploratory study. Tob Control. doi:10.1136/tobaccocontrol-2011-050303

Conflict of Interest:

Pro bono director of a cold turkey quitting forum.

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.