Tobacco Control Seminar UCT-ICO-WHO

1. Simon Chapman
University of Sydney

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3. Three heretical papers
43,000 downloads

4. More recently ..
Smith A, Chapman S, Dunlop S. What do we know about
unassisted smoking cessation in Australia? A systematic review
2005-2012. Tobacco Control 2013; doi:10.1136/tobaccocontrol-
2013-051019
Smith A, Chapman S. Quitting unassisted: the 50 year neglect of
a major health phenomenon. JAMA 2014;311(2):137-138.
doi:10.1001/jama.2013.282618.
Smith A, Carter SM, Chapman S, Dunlop S, Freeman B. Why do
smokers try to quit without medication or counseling? A
qualitative study with ex-smokers. BMJ Open 2015;
5:e007301 doi:10.1136/bmjopen-2014-007301
Smith A, Chapman S, Carter SM, Dunlop S, Freeman B. What
are the views and experiences of smokers who quit smoking on
their own? A systematic review of the qualitative evidence.
PLoS One May 26, 2015 DOI: 10.1371/journal.pone.0127144
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5. Inverse Impact Law of Smoking Cessation
“the volume of research and effort devoted to
professionally & pharmacologically mediated
cessation is in inverse proportion to that
examining how most ex-smokers actually quit.
Research on cessation is dominated by ever-finely
tuned accounts of how smokers can be
encouraged to do anything but go it alone when
trying to quit―exactly the opposite of how a very
large majority of ex-smokers succeeded.”
Chapman S. Lancet 2009; 373(9665):701-3

6. “natural recoveries from substance use disorders not only occur
but are a common pathway to recovery”

7. Most with dependencies who quit do so unaided
 Problem drinking
 Narcotics use
 Gambling
 Eating disorders
 Smoking
 1986: American Cancer Society : ‘‘Over 90%
of the estimated 37 million people who
have stopped smoking in this country since
the Surgeon General’s first report linking
smoking to cancer have done so unaided.’’
 100s of millions worldwide

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9. WRONG!
“There are
some people
who can go
cold turkey
and stop. But
there aren’t
many of
them.”

10. 29,537 adult smokers
Unassisted: n= 7714 x 20.6% abstinent = 1589
Pharm: n= 3407 x 19.3% abstinent = 675
2.35 x more quit unaided in the population
2008

11. Meta-analysis of 12 NRT
RCTs with final follow-
up >12m (2408 active &
2384 placebo
participants).
RCTs of NRT: 93% fail after 12
months
“the true overall
impact of NRT .. is
similarly modest and
represents success for
only about 7% of all
those treated in these
trials.” (ie 93% fail)
Is there any recommended drug with a 93% failure rate?

12. How much better is NRT?
Cochrane: >130 studies: NRT 50-70% greater
success than placebo
But: trials over-estimate real-world effects
trialists get drugs free of charge
Hawthorne effects caused by the research
attention paid to them (average 7.6 per subject),
regular reminders and subjects’ desire to please
researchers with whom they interact during trials
Exaggerate real-world effects?

13. Generalisability of findings from clinical trials to “real
world”?
66% participants with nicotine dependence excluded
from RCTs by at least one criterion (esp. mental health).
 Le Strat et al: How generalisable to community samples are clinical trial results for treatment
of nicotine dependence? Tob Control 2011;338-43

14. NRT trials have poor blindness integrity:
many on placebo know
12/17 studies that tested for
blindness integrity found
subjects accurately judged
treatment assignment at a rate
significantly above chance
Mooney et al: The blind spot in the NRT literature:assessment of the
double-blind in clinical trials. Addictive Beh 2004;29:673-84

15. Pierce et al: Ann Rev Pub Health, 2012
“These results have
encouraged
governments to
recommend strongly
that pharmaceutical
aids be used in all
quit attempts .. To
date, there is no
evidence that such
policies lead to an
increase in cessation
in the population.”

16. Pierce et al. Quitlines and nicotine replacement for smoking cessation: do we
need to change policy? Ann Rev Pub Health 2012;33:1-16
Real world cessation: unassisted is superior

17. Displacement of treatment, with no
population impact?
Zhu H-S et al
Quitting smoking before and
after varenicline: a population
study based on two
representative samples of US
smokers.
Tob Control
doi:10.1136/tobaccocontrol-2015-
052332
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19. Indication bias: more addictive use meds …
prognosis worse
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20. Increased quit
attempts, but little
increase in 3-month
quit rates
Zhu SH et al. Interventions
to increase cessation at the
population level: how much
progress as been made in
the last two decades? Tob
Control 2012:21: 110-18
1992-2010, USA

21. Australian impact?
• monthly data on Australian
smoking prevalence from
1995-2006, assessing impact
of televised anti-smoking
advertising, cigarette price,
sales of NRT & bupropion, &
NRT advertising.
• Neither NRT or bupropion
sales nor NRT advertising
had any detectable impact on
smoking prevalence across
the 12-year period
• Anti-smoking advertising
and price did
Wakefield et al. Am J Pub Health 2008;
98:1443-50

22. Association for the Treatment of Tobacco Use
and Dependence (2012)
NRT “is currently marketed for short-term use as an aid
to smoking cessation. Over 100 randomized studies have
found NRT increases short term abstinence and in these
studies, after NRT has stopped the rate of relapse back to
smoking does not differ from that of smokers who quit
without treatment. The benefit of treatment is of
increasing the initial quit rates not preventing relapse.

23. In response to
Alpert et al study
(Tob Control 2012)
“We are not surprised at the
results of this study, because
evidence is accumulating that
smokers who use NRT do not
often use it as directed, nor do
they use it long enough to stave
off relapse, suggesting that we
need to educate NRT users better
(and the physicians and
pharmacists who recommend it)
and convince the FDA that 12
weeks is not long enough for NRT
to be maximally effective.
Solution? Take it for longer!!

24. “Most of the studies were performed on people smoking more than 15
cigarettes a day” & “no benefit for using patches beyond 8 weeks”

25. Few interested in support
3.6% of smokers call quitline
Miller CL, Wakefield M, Roberts L. Uptake and effectiveness of the Australian telephone Quitline
service in the context of a mass media campaign. Tob Control 2003;12 Suppl 2:ii53-8.
1.4% of US smokers call quitlines (2010 data)
UK: in area with highest participation at clinics, 6%
attended
Prospects for higher engagement with support very poor

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Compliance very poor
7.2% (active) & 2.8% (placebo) used for >1 month
New Engl J Med 2012;366:808

27. Irresponsible or subversive information?
Rarely emphasised in information to smokers
Few campaigns ever mention it
Cursory attention in reviews
Framed as a challenge to be forcefully eroded
“Unfortunately, most smokers .. fail to use
evidence-based treatments to support their quit
attempts”
“If there is a major failing in the UK approach, it is
not that it has medicalised smoking, but that it
has not done so enough.”

28. How difficult is quitting?
Much harder than expected: 25 (1.6%)
Harder than expected: 87 (5.5%)
Total HARDER: 7.1%
As expected: 674 (42.8%)
Easier than expected: 463 (29.4%)
Much easier than expected: 325 (20.6%)
Total EASIER: 50%
Source: recently reviewed paper, military sample
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29. • When citizens have
common, ordinary and
self-limiting ailments,
traits and behaviours
constantly redefined as
needing treatment … the
steady erosion of human
agency and self-efficacy as
populations lose
confidence in their ability
to recover or change
unhealthy practices is of
great concern
• Overly deterministic and
disempowering?
Consequences of over-pathologising cessation?

30. Can we afford both?
Maybe in wealthy
nations ..
Indonesia: 3 months NRT
costs as much 7 year’s
supply of cigarettes
Emphatically no!
Cambodia: $36.80, $20.40, $58.10

31. What should we tell smokers?
1. unassisted cessation the most common way that most
smokers have succeeded in quitting. Unequivocally a positive
message - should be openly embraced as front-line, primary
“how” message in all clinical encounters & public
communication about cessation.
2. Along with motivational “why” messages designed to
stimulate cessation attempts, smokers should be repeatedly
told cold turkey is method most commonly used by
successful ex-smokers;
3. More smokers find it unexpectedly easy or moderately
difficult than find it very difficult to quit;
4. “Failures” are a normal part of the natural history of
cessation – rehearsals for eventual success.
5. 5. Assistance is a second-line strategy for those who really
need help.

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http://www.quit.org.au/keep-quitting/