(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 !
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
Pages