The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences
Authors: Simon Chapman, Ross MacKenzie
Journal: PLoS Medicine (2010)

As with problem drinking, gambling, and narcotics use [1]–[9] population studies show consistently that a large majority of smokers who permanently stop smoking do so without any form of assistance [10]–[15]. In 2003, some 20 years after the introduction of cessation pharmacotherapies, smokers trying to stop unaided in the past year were twice as numerous as those using pharmacotherapies and only 8.8% of US quit attempters used a behavioural treatment [16]. Moreover, despite the pharmaceutical industry's efforts to promote pharmacologically mediated cessation and numerous clinical trials demonstrating the efficacy of pharmacotherapy, the most common method used by most people who have successfully stopped smoking remains unassisted cessation (cold turkey or reducing before quitting [16],[17]). In 1986, the American Cancer Society reported that: “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.” [18]. Today, unassisted cessation continues to lead the next most successful method (nicotine replacement therapy [NRT]) by a wide margin [15],[16].

Yet, paradoxically, the tobacco control community treats this information as if it was somehow irresponsible or subversive and ignores the potential policy implications of studying self-quitters. Unassisted cessation is seldom emphasised in advice to smokers [19]. We know of no campaigns that highlight the fact that most ex-smokers quit unaided even though hundreds of millions have done just that. Reviews typically give unassisted cessation cursory attention [20], framing it as a challenge to be eroded by persuading more smokers to use pharmacotherapies: “Unfortunately, most smokers …fail to use evidence-based treatments to support their quit attempts” [21]; “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.” [22]. Clinical guidelines also ignore unassisted cessation [8]. Finally, although the US National Center for Health Statistics routinely included a question on “cold turkey” cessation in its surveys between 1983 and 2000, this question disappeared in 2005 [23].

Because of these prevalent attitudes, smoking cessation is becoming increasingly pathologised, a development that risks distortion of public awareness of how most smokers 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 [24], many ex-smokers recall stopping as less traumatic than anticipated. For example, in a large British study of ex-smokers in the 1980s, before the advent of pharmacotherapy, 53% of the ex-smokers said that it was “not at all difficult” to stop, 27% said it was “fairly difficult”, and the remainder found it very difficult [25].

We recently hypothesized that research into smoking cessation follows what we call “the inverse impact law of smoking cessation.” This law posits that “the volume of research and effort devoted to professionally and 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 opposite of how a very large majority of ex-smokers succeeded.” [26]

In this Policy Forum, we test this law and, because a recent review of Cochrane selected randomized controlled trials of NRT [27],[28] found that while 51% of industry-funded trials reported significant cessation effects, only 22% of nonindustry trials did, we also test the hypotheses that research on pharmaceutically mediated cessation is frequently conducted by researchers supported by pharmaceutical companies and that support for research into unassisted cessation and nonpharmaceutical interventions is less common. Throughout this Policy Forum, by assisted cessation, we mean any pharmacotherapy or any individual or group behavioural or cognitive intervention. By unassisted cessation, we mean approaches that involve none of these interventions but instead include interventions such as changes in tobacco tax, smoking restrictions, or public awareness campaigns designed to stimulate cessation. We then consider why research into how most people stop smoking is being neglected and reflect on the potential negative consequences for public health of repeatedly megaphoning the message that “serious” cessation is assisted cessation, a message that implies that unassisted cessation is less worthy of research attention, publicity, and consideration by quitters. Finally, we suggest how the message that smokers are getting about cessation should be adjusted to help more people quit.