How to quit smoking

[Thomas3.20.2010]

Some researchers say the growth of nicotine substitutes is clouding the only real way to give up cigarettes - make a firm decision and go cold turkey. Health reporter Martin Johnston looks at the evidence

Former smoker Scotty Darnill hoped nicotine skin patches would help him quit cigarettes. But for him, they turned out to be useless.

"I actually found I carried on smoking. That was six or seven years ago. I was starting to think 'I've had enough of smoking' and I always kept thinking about those withdrawal symptoms that everyone talks about, that I needed something just to cover it, so I got the patches at the chemist.

"It made no difference to me. I still smoked," says the 46-year-old from Pukekohe, who sells leases for trucks and is a volunteer fireman.

"I was hoping it would take away the feeling that I needed to have a smoke - and it probably wasn't until I stopped last year that I realised that that feeling actually for me wasn't the craving but the habit."

Darnill quit at 4.30pm last September 9. He chewed a few pieces of nicotine gum - given to him by a workmate - but disliked them, so didn't continue with the 12-week course recommended by the makers. Quitline gave him a prescription, which he never filled.

Instead, he credits what he considers his cold-turkey success to a making a clear decision and the support of other, anonymous quitters on a Quitline internet blog site.

His quitting method puts him in a controversial majority of ex-smokers. Controversial because some tobacco control researchers, such as Simon Chapman, are questioning the effectiveness of cessation drugs, now central to many state-funded quit programmes, and urge that more emphasis be placed on unassisted quitting.

They cite a paper in the journal Tobacco Control last month by Hillel Alpert, of Harvard University, on study findings that ex-smokers relapsed at equivalent rates whether or not they used nicotine replacement therapy to help them quit.

"Before these [drugs] were invented in the early 1980s, the American Cancer Society said more than 30 million people had quit in the 1960s and 70s," Chapman, professor of public health at Sydney University, told the Weekend Herald. "There will be hundreds of millions of people around the world in the 60s and 70s who quit unaided.

"Now, with the messages about how we quit smoking, the opposite applies. Most of the messages say if you want to quit smoking, you shouldn't try to do it yourself; you should use pharmacotherapies like nicotine replacement therapy."

"I'm not saying they don't work and are no good to anybody; just that the message has become very distorted, that 'you won't be able to do it by yourself', that 'you need to use these products'," says Chapman, who is planning an interviews-based study of unaided quitting.

He and Macquarie University colleague Ross MacKenzie lamented in a medical journal how unhelpful it was that quitting had become medicalised and that this risked distorting public awareness of how most people quit, "to the obvious benefit of pharmaceutical companies".

"Furthermore, the cessation research literature is preoccupied with the difficulty of stopping. Notably, however, in the rare literature that has bothered to ask, many ex-smokers recall stopping as less traumatic than anticipated."

They cite a large British study from the 1980s, prior to quitting drugs becoming available: 53 per cent of the ex-smokers reported it was "not at all difficult" to stop, 27 per cent that it was "fairly difficult" and the rest found it very difficult. Other research had found that at least two-thirds of ex-smokers had stopped unaided.

Darnill says his decision to quit was "like an awakening. What the hell am I doing this for? It doesn't achieve anything. I just didn't like being addicted."

Before stopping, he smoked at least 25 cigarettes a day, Holiday Reds. He took up the habit in his late teens.

Cigarette cravings lasted for a month after he quit. Harder to withstand were the habits, the almost unconscious rituals that for nearly 40 years had woven the practices of smoking into virtually every part of his daily life.

"You get to work in the morning, you have a smoke - coffee, smoke; lunch, smoke; on the phone. I would always do my phone calls outside so I could have a smoke."

After he quit, when his cellphone rang he found himself standing up and walking towards the door befor in and reminded him: "hang on, I don't do that anymore".

He admits it was difficult sticking to his decision in the first month, during which he got "a wee bit snappy - my wife will tell you that". Linda is a non-smoker and dislikes smoking.

But it was all about changing the details of his life. In the past when he tried to quit, he wasn't clear in his mind why he wanted to.

"You're always looking for an excuse to have a cigarette when you stop if you're not 100 per cent in your mind.

"Let's say you had a really stressful day at work and you think, 'I'll just have that one cigarette, it will make it better'. Well that starts you again, you're gone.

"So this time I made sure I stayed positive in my attitude towards it and didn't try to find an excuse. If it was a stressful day at work or we had a bad job at the Fire Brigade, I just learned to deal with it. In the past you would have a smoke, thinking that it relaxed you. Well, actually it didn't and I found just sitting down and having a glass of water, that was five minutes away from the computer or whatever I'm dealing with, actually is just as good."

In 2010, the Government predicted its tax-take from tobacco next year, following the 33 per cent-plus excise increase - its key quit-smoking policy - would exceed $1.3 billion. But that falls well short of the Health Ministry's estimate that smoking's health costs are around $1.9 billion. Smoking-related illnesses kill up to 5000 people a year.

The Government, which is committed to New Zealand's becoming smokefree by 2025, spends about $67 million a year on tobacco control, including $9 million for Quitline and its phone counselling service.

Nearly $13 million goes on nicotine replacement therapy (NRT) and $14.5 million on three other smoking cessation drugs - Champix, Zyban and nortriptyline - although Pharmac says these figures exclude "confidential rebates", patient contributions and pharmacy costs.

There are uncertainties around how many smokers use NRT, because of gaps in the recording of their health identification numbers, but it was probably around 210,000 in the last financial year. That's nearly a third of adult smokers - it is estimated that 650,000 or around 20 per cent of the adult population smoke.

Adults' smoking prevalence has declined greatly since 1976, when it was 36 per cent, but has dropped little since 1992, when it was 23 per cent.

Given this small reduction since NRT was subsidised in 2000, is it a good taxpayer investment?

"Absolutely," says Karen Evison, the Health Ministry's head of tobacco control.

She explains the apparently limited effect of NRT on smoking prevalence by pointing to people continuing to take up the habit (although mid-teen prevalence is declining) and the "relatively minor" use of the drug until 2008/9.

That was when the rules were changed to give quitters subsidised access to NRT on a doctor's prescription; previously the subsidy was only available through the Quitline. It was also when health workers were required under the Government's revamped health targets to ask hospital patients if they smoked, encourage smokers to quit and offer quitting treatment.

NRT use has been increasing since then, but there have been no national smoking surveys since 2009, so whether it has reduced will not been known for several months.

But Evison says "strong anecdotal evidence" - localised studies with small samples - indicates "we are making a difference".

One is from Middlemore Hospital's emergency department. Of 86 recent patients who had been smokers and recalled receiving quitting advice at the ED, 17 reported they had reduced their smoking and 51 had attempted to quit.

At four weeks, 26 were smokefree and 14 were still smokefree after three months.

The dispute over NRT's effectiveness is essentially about research methods.

The strong supporters of using quitting medicines say they at least double the chances of a smoker's being smokefree at 12 months follow-up, from - depending on the study - 3 to 8 per cent cold-turkey, to 15 to 20 per cent.

Auckland University researcher associate professor Chris Bullen says there is a "huge weight of evidence" for this superior effectiveness of the medicines, from good quality clinical trials in which patients are randomly allocated, to treatment with a new therapy or either standard care or a placebo - so-called randomised, controlled trials.

"We are getting around 20 per cent here in New Zealand with the Quitline service and with our randomised trials which [compare] people who have a new intervention, and usual care," says Bullen, the director of the university's Clinical Trials Research Unit.

Chapman, however, asserts that the clinical trials of quit drugs, many of which were funded by drug companies, produce unrealistically positive results.

Participants tend to be highly motivated people, compliance with medication is higher than in the general population, the mentally ill, typically a hard-core smoking group, are excluded, and nicotine addicts in the placebo arm of a trial will soon know they are not getting their nicotine and will often have a high relapse rate.

Bullen responds: "We conduct our randomised controlled trials for smoking cessation interventions [such as patches and very-low-nicotine cigarettes] in very much a real-world setting.

"We have recruited participants through callers to the Quitline, so the intervention is run through the Quitline, just like the normal service. We try and make the interventions a pretty minimal change to what people would usually get."

"We are not tainted by industry funding; our work is public-good funded ... by the Health Research Council.

"Randomised controlled trials eliminate the risk of most of the biases that you get in some of these non-randomised studies such as the one Alpert reports on."

Criticisms of the Alpert paper include that because its participants chose their quitting method rather than being randomly allocated either to cold-turkey quitting or to NRT, the NRT users might have been affected, for instance, by factors that predisposed them to relapsing and which were not measured.

"You might choose to use NRT if you have tried numerous times before [to quit] but haven't succeeded," says Hayden McRobbie, a British quit-smoking specialist and academic, a colleague of Bullen's and co-author of New Zealand's Smoking Cessation Guidelines.

"That may be a factor of tobacco dependence, but also of other things not measured, for example living with smokers, being in lower socio-economic groups."

He says the Alpert paper doesn't lead to the conclusion that NRT is useless. "My reading of that paper was that relapse rates didn't differ between groups. You wouldn't expect relapse rates to differ. NRT is used primarily short-term. The goal in the short-term is to increase quit rates. We know people are still going to relapse over time. We don't have good interventions to prevent relapse."

One point where there is agreement is the value of encouraging smokers to make quit attempts, because of research evidence of just how many attempts long-term smokers make before they stop permanently. Typically 20 attempts by the age of 40, according to McRobbie.

"I tell my patients stopping smoking is like learning to ride a bicycle. Some people learn quickly. Others get on, fall off, ride a bit, fall off."

The theory is that "tension" factors like tax hikes, gruesome warnings on tobacco packets, plain packaging (forthcoming in Australia and under consideration here) and restrictions on where people can smoke all increase the motivation to quit. The official line then is to increase the quitting rate by providing treatment for those who want it.

Scotty Darnill didn't want it, but still he is loving the changes in his life from quitting.

"I'm enjoying the taste of food again. I'm looking at different foods, fruits and vegetables, where before I would be quite happy just having a big hamburger. Strawberries taste a hell of a lot better than they used to.

"Your sense of smell is the other thing that comes back. I have learned how much a smoker stinks after they have had a cigarette. It's not nice."