Betreff: [cessation] Re: Unassisted cessation
Von: "Mr. Joel Spitzer"
Datum: Thu, 11 May 2006 21:05:38 +0200
An: "GLK Cessation"
                                            webmaster's comment: see also Cochrane 2010 update on motivational interviewing,,
Re: Unassisted Cessation

I am going to attach a commentary that I wrote a few years back and have posted at At the end of the commentary is a link to the original article, so that you can see the actual American Cancer Society chart being talked about and a link back to the original American Cancer Society publication.

I have truly been amazed on how real world experiences seem to be totally ignored by the smoking cessation research community. Actually, I don't believe that the researchers who participate here at Globalink are going to find anything credible in this commentary. It is really overly simple. It was not written to influence or change the mind of people in the research community. It was written for the general public.

I do however think that health care practitioners who read here, and maybe public health officials--people who really are out there on the front lines dealing with! individuals or the public in real world settings and who may be frustrated with how their interventions seem to go with their patients or their community--that these people may benefit from reading this commentary as well as really paying attention to the discussion that Simon Chapman's observation is spawning here.

There are a few other commentaries that I have put up at over the years that touch on some of these issues. I am going to attach links to these articles too.

Joel Spitzer

So how did most successful ex-smokers actually quit?

If you look around the Internet or even request information from professional health organizations on how to quit smoking you are likely to find that the standard advice given is to use a pharmacological approach, i.e., nicotine replacement products and or Zyban. Each time you see this advice you will also be told that these approaches double your chances of quitting. Some sites and gr! oups come out and almost say, point-blank, do not go cold turkey--basi cally leaving the reader with the impression that nobody could possibly quit this way.

The American Cancer Society's Cancer Facts & Figures 2003 report contains a chart which shows the percentage of current smokers who have tried different routes at quitting smoking and also indicates the percentage of current ex-smokers who quit by different techniques.

The numbers that are highly telling are the percentages that indicate how former smokers had actually quit. Keep in mind that this chart is limited. It does not tell us how long they had quit or other key pieces of information, such as, did the people who used quitting aids such as NRT ever actually get off the NRT. But I am not concerned about that at this moment.

According to the American Cancer Society report, how did former smokers actually quit? Those using drug therapies and counseling had a 6.8% quitting rate while those using other methods 2.1%. The remainder quit cold-turkey or cut down! . In that it is generally accepted that cutting down techniques do not work, we can safely assume that they had an extremely limited impact upon the overall number. So, approximately 90% of the people who are successfully classified as former smokers quit cold turkey. On the same page as Table 3 is located you will find the following recommendation:

"All patients attempting to quit should be encouraged to use effective pharmacotherapies except in the presence of specific contraindications."

You have to ask yourself how many of the successful ex-smokers in the world today would have actually succeeded if they sought out and listened to "professional" advice such as this.

If you are trying to determine what is the best way to quit, you have a choice. You can go with the "experts" or you can go with what 90% of successful quitters have done.

Take Your Own Survey

So how do most people really quit smoking? Don't take our wor! d for it, or the American Cancer Society's, but instead talk to every long-term ex-smoker you personally know. See how many of them fall into one of the following three categories:

1. People who woke up one day and were suddenly sick and tired of smoking. They tossed them that day and never looked back;

2. People who get sick. Not smoking sick, meaning some kind of catastrophic smoking induced illness. Just people who get a cold or a flu and feel miserable. The feel too sick to smoke, they may feel too sick to eat. They are down with the infection for two or three days, start to get better and then realize that they have a few days down without smoking and decide to try to keep it going. Again, they never look back and stuck with their new commitment; or

3. People who leave a doctors office given an ultimatum. Quit smoking or drop dead--it's your choice. These are people who some sort of problem has been identified by their doctors who lays out in no uncertain terms that the person's life is at risk no! w if they do not quit smoking.

All of these stories share one thing in common--the technique that people use to quit. They simply quit smoking one day. The reasons they quit varied but the technique used was basically the same. For the most part they are clear examples of spur of the moment decisions elicited by some external, and sometimes unknown circumstance.

I really do encourage all people to take their own survey, talking to long-term ex-smokers in their real world: people who you knew when they were smokers, who you knew when they were quitting and who you still know as being successful long-term ex-smokers. The more people you talk to the more obvious it will become how people quit smoking and how people stay off of smoking. Again, people quit smoking by simply quitting smoking and people stay off of smoking by simply knowing that to stay smoke free that they must Never Take Another Puff!


Original article:

Other related readings:

The Setting Quit Date article linked above is another example of how researchers try to ignore the obvious conclusions of a study and slant research to fit the agenda of selling medications to help people quit.

Here is a commentary that I wrote in reply to an comment written at the British Medical Journal response board in the article "Catastrophic" pathways to smoking cessation: findings from national survey"

(see full story at

A response was written there saying:

"...because something commonly happens in a particular way 'in the real world' then this should be considered the best way."

Smoking cessation experts often seem to have to be telling people to dismiss real world experiences. Usually I see a little different variation of the comment above. Common statements I have seen are something to the effects that while it is likely that a person may at times encounter real world quitters who succeeded by using non-recommended techniques, usually meaning no pharmaceutical intervention or in what this study is showing, people who used no set quitting date, that these people are just the exceptional cases. What the experts are trying to do in effect is discredit observations made by people, making them think that the occurrence of such experiences are really rare.

The author above was at least accurate enough to say, "While it i! s true that most smokers who quit do so without any specific behaviora l support or pharmacological treatment..." The rest of the comment was going on to try to give the impression that there would have been even more successful quitters if people would just do what smoking cessation experts say should work as opposed to doing what actual quitters continually say has worked for them.

The tactic being employed here is to leave the impression that we could just have a whole lot more successful quitters if people would just utilize the miraculous effective products out there that actually help people to quit. There is also the perception being portrayed that there really are very few ex-smokers out there because most who have tried to quit have done so unaided and everyone just knows how improbable it is for people to be able to quit in an unaided attempt.

Medical professionals and the general public are being misled to believe that quitting smoking is just too plain difficult for people to do on their own and that the odds of ! a person actually quitting on their own is really pretty dismal.

This would all make perfect sense if not for the fact that we have so many successful ex-smokers in the real world. In America, we have more former smokers than current smokers. Over half of the people who used to smoke have now quit smoking. From the comment made above it should be clear to all that most of the people who have quit either did not know of professional recommendations for quitting or chose to ignore professional intervention techniques. Yet these people successfully quit anyway. I think that this is an important point to hit home with all medical professionals. The medical profession has got to start to help people to realize the real potential of success that individuals do have to quit smoking instead of perpetuating the idea that quitting is just too hard for an individual smoker to expect to actually succeed without help.

While this article should have been about plannin! g techniques, the original author and a few experts weighing in on the discussion have tried to turn it into a referendum on selling pharmaceutical interventions. Nicotine replacement products have been around for over two decades now-- and a significant percentage of smokers have used them to try to quit smoking. If a product has been around for decades, used by millions of people worldwide, AND, has been truly effective, it should be easy for most health care practitioners to come up with lots and lots of successful patients, colleagues, family members and friends who have quit with these products.

As I said in my original commentary above:

" I don't believe that there is a single professional smoking cessation "plan your quit" advocate who will suggest other medical professionals should take a similar survey. For if they did their study results would almost certainly be called into question when the health care professional starts seeing the results of his or her real life survey. The experts will end up having to spend ! quite a bit of time trying to explain away the discrepancy, using rationalizations like the people who planned their quit "didn't do it right" or didn't "plan" long enough or were "just more addicted smokers."

In all honesty, I don't expect my encouraging of real world observations by health care professionals to have much impact with smoking cessation experts. They are going to profess to believe whatever other experts keep telling them to believe or, what the funders of their studies believe.

I do however believe that health care workers who are on the front line and actually deal with patients who smoke are going to be a bit more critical and analytical about this. If they spend any time talking with patients they are going to see through the rhetoric and the rationalizations of the experts.

I have always tried to disseminate the message that just because something works in the lab or in study conditions doesn't necessarily translate to the ! fact that the process will work in the real world. The smoking cessati on experts seem to have to work on the basis that just because something works in the real world doesn't mean that it is a good approach if it doesn't seem to work in a lab.

I have high hopes that medical professionals really wanting to help their patients are going to be more influenced by what they see is successful than by being told by the experts what should be successful, but somehow not replicable in their own practices.

One more example of how researchers or policy makers make what I believe are unwarranted or unsupported conclusions or recommendations to specific data interpretations. It happened back in 2003 in the Malta Medical Journal.

Here is a link to the study:
Excerpts from that PDF file

Quantitative Results
There were 246 applicants who applied for the 13 smoking cessation clinics organised by the ! Health Promotion Department in Malta during the year starting in October 1999. Out of these, only 134 presented themselves for the introductory session, with this number falling to 101 for Session No. 2 - the quit session (see Table 2). While the immediate success rate at the final session was 27% (n=27) as a percentage of the participants attending the quit session, the six-month success rate dropped to 10% (n=10), with dropouts being counted as smokers.

Of these ten quitters who were still not smoking at six months after the end of the clinic:

• seven were males, while three were females;

three were aged 30-39 years (30%), two were between 40 and 49 years old (20%), four were in their 50’s (40%), and one was 64 years old;

• nine were continuously abstinent for the whole duration of the six months (one male had re-started smoking, only to quit again 3 months before the six-month follow-up);

• and only two (20%) had used nicotine! replacement therapy as an aid to stopping.

Implications for improving the outcome

The 10% prevalent abstinence rate (9% continuous abstinence rate) at six months after the end of the Malta clinics is low compared to international standards (20-30% in the UK16 and 15-30% in the USA1), particularly as these are measured at one year, and assuming no differences in the methods used and their application. One significant factor that may account for this difference is the freedom of choice for use of pharmacotherapy (in this case, nicotine replacement therapy). While UK and US recommendations1,6,7,14,17 put pharmacotherapy (NRT and bupropion) as the cornerstone of therapy, Maltese smoking cessation clinics still leave the choice for use or non-use of NRT to the participants. In fact, of the 10 quitters who were not smoking at six months after the end of their respective clinics, only two (20%) had used nicotine replacement therapy.

Then from table six of that study:
Table 6: Recommendations of study

The! use of pharmacotherapy (NRT and/or bupropion) as a cornerstone of smoking cessation clinics.

Again, they disregarded the fact that the majority of success was seen with the people who did not use pharmacotherapy and instead said that one of the problems is that participants had too many choices, and the "logical" conclusion was somehow to make pharmacotherapy the cornerstone of treatment.

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