National Working Group for ACTTION

July 27, 2010

Simon Chapman is a Professor of Public Health at the University of Sydney. He was deputy editor, then editor of Tobacco Control for 17 years.  For more than 25 years, he has written on the need to invest more resources in campaigns that motivate cessation in smokers and less on pharmacotherapy.  He emphasizes that the large majority of smokers who permanently stop smoking do so unaided.  The results from clinical trials on selected participants with special conditions may differ from results in real world situations, and most importantly, may have different results for long term abstinence. “ActionToQuit” asked Professor Chapman to answer questions about his views on unassisted cessation for this newsletter.

ActionToQuit:
What do you mean when you say “unassisted cessation”?

Simon:
Smokers deciding to quit are plainly “assisted” in their decision to stop by a complex and continually changing array of cultural and economic factors, including everyday interactions they have with their families, friends, colleagues, health care providers and what they see and hear in the news media about smoking. We all need to foment these factors to assist in encouraging quit attempts. But by “unassisted” I mean cessation that is not mediated through either dedicated professional face-to-face cessation services or any form of pharmacotherapy, including Nicotine Replacement Therapy. Prior to the advent of modern cessation pharmacotherapy and NRT, millions of people stopped smoking without assistance. Many of them were heavily addicted. Today, more than 20 years after NRT and its massive associated marketing efforts, unassisted quitting remains easily the leading way used by people who have successfully stopped smoking. This is a message that is rarely given to smokers. Worse, it is actively discouraged.

ActionToQuit:
What about 5 A’s (Ask-Advise-Assess-Assist-Arrange)? or brief 3 A’S? (Ask, Advise, and Refer)?  Can any of the A’s—ask and advise for instance—be part of unassisted cessation?

Simon:
Of course. It would be very strange for anyone to argue that health care workers should not try to raise the importance of quitting for health. I am fully supportive of exploring how this can be done most effectively within the typical constraints of health care consultations. That said, we must also not lose sight of the fact emerging from recent research that many, perhaps most, smokers take decisive and effective steps to quit apparently in isolation of any recent attributable “intervention”. They eventually decide the time is right and, as the saying goes, “just do it” – globally, hundreds of millions of them. There are likely to be important lessons in studying this “natural history of smoking cessation” but our paper showed that the cessation community is preoccupied by researching the “tail” not the “dog”.

ActionToQuit:
Is there a role in smoking cessation for NRT or medication?  Is there a point—after failed attempts—when a smoker should turn to “assisted” cessation?

Simon:
Undoubtedly, and that “point” will vary enormously. But today, smokers are inundated with pharmaceutical industry marketing that constantly megaphones the message “It’s very hard to quit. You will almost certainly fail if you try alone. You’ve probably tried before and failed, so you know we are right. You can double your chances of success by medicating yourself.”  Each part of that message can be contested, particularly if we accept that many “attempts” are trivial and unworthy of the name. I am not at all inclined to the view that there is some magic number of failed attempts after which medication should become the dominant conversation with smokers. But I am trying to champion the idea that we should regain lost perspective on cessation that has been colonized mostly by pharma-interventions. We should restore people’s understanding of the idea that there was cessation before meds and groups – lots of it – and that unassisted is still the way that most people quit. If unassisted was a drug, someone would have patented it by now.

ActionToQuit:
What about quitlines?  You have been critical of the reach of quitlines—about 1.4% of U.S. smokers have called them—and the amount of resources they consume.  Do they have a role?  Many cessation advocates recommend that health professionals refer their smoking patients to quit lines as way of providing cessation assistance without having to spend a lot of time on the issue.

Simon:
Quit lines are a relatively low-cost way of offering support to potentially large numbers of people leading busy lives who are trying to quit. But we need to face up to the fact that despite nearly universal regret among smokers about having started smoking, and very widespread intentions to quit, that only low-end single digit percentages of smokers are even willing to pick up the phone. In Australia, we have one of the largest public awareness quit media campaigns in the world. Every TV spot features the quitline number. It has been on every pack for over a decade. Yet less than 4% of smokers ever call it. There is a whole PhD industry out there obsessing about how to move 4% to, say, 6% because there’s scant evidence anywhere that you can get higher involvement. I want more attention paid to learning from the 96% who just are not interested in being “helped” to do something which they know from talking with many ex-smoking friends and colleagues can be done without help. How can this 96% be better stimulated to end their smoking?

ActionToQuit:
What would be your ideal cessation program?  I know that you have identified messages that smokers should receive about cessation—in many countries there are more ex-smokers than smokers; unaided cessation is the most common method used by most ex-smokers (as many as ¾); a serious quitting attempt need not involve NRT, drugs, or professional support; failure is part of the process; pharmaceuticals and counseling may help, but are not necessary.  How do you craft a program around this?

Simon:
Rather easily. We could start by daring to include questions in our national studies of cessation where we ask ex-smokers to rate the difficulty they experienced.  This is rarely asked although it is asked constantly of relapsed ex-smokers. The information we would get is likely to be highly subversive: many ex-smokers found it far easier than they expected and now wonder what all the fuss was about. From the information gained,  we could forge a whole new discourse that says “it can be hard, but here are strategies we have learned from people who have done it successfully. And – wait for this – many ex-smokers find it surprisingly easy.”

ActionToQuit:
How do you measure success?  What time frame do you use to define long term abstinence?  Do you distinguish between rates of successful quitting and absolute numbers of successful quitters, and if so, why?

Simon:
I get impressed at 12 months of continual abstinence. But there’s a whole science to that question which I don’t think takes us any place really interesting in this present discussion. If our goal is to reduce smoking in whole populations, then numbers are what ultimately count. If a strategy with a low rate of success produces much bigger success numbers than one with a higher success rate and much lower participation, the low rate strategy is far more important. Unassisted cessation has high participation, and delivers lots of big numbers. If we took it more seriously, it might deliver a whole lot more. 

ActionToQuit:
Why do you think that overcoming the bias in favor of assisted cessation is important?  Why are you troubled by the emphasis on cessation programs that use pharmaceuticals and counseling?  Do you think this emphasis holds smokers back from trying to quit? Is there harm being done by promoting the Public Health Service Clinical Guidelines?

Simon:
I think a society produces spiritually flabby citizens when it constantly tells them that they cannot do ordinary things without help when we know, by looking around us, that millions of people actually can do these things if they are encouraged and motivated. Learn a craft, a new language, a musical instrument, get fit, become a great cook, do home and car repairs, sell your house yourself rather than through a realtor and stop smoking.  I am instinctively suspicious of efforts to unnecessarily reduce human agency.

I am not saying that professionals have no role in cessation—far from it. Professionals can assist in all the things I’ve just mentioned. But I am saying the “you need help” message has now gone way overboard at the urging of the pharmaceutical industry, for obvious reasons. If people are constantly told they cannot quit alone, and hear a loud chorus of professionals uncritically singing the same tune, we should expect that many will come to believe it.