Friday, February 09, 2007

Smoking Cessation: Drugs or Cold Turkey?

Recently, I was involved in the management of a patient who smoked regularly 2-3 packs a day of cigarettes and presented to our Emergency Room with shortness of breath from atrial fibrillation and a very fast heart rate. Since this had been going on so long, he had also had the misfortune to develop heart failure (fluid on the lungs). We treated him with diuretics and heart rate-control medications and then admitted him to the hospital. Since I now have learned how to record his history in our electronic medical record, I dutifully entered his smoking history.

Little did I know what would happen next.

As I wrote the orders for admission, I was surprised to see a little "reminder" box pop up that I should offer this patient a nicotine patch. What?? A computer pushing drugs?

Well it seems that nicotine patches are now part of the federal guidelines regarding smoking cessation issued by the Public Health Service, a division of the Department of Health and Human Services. But an interesting twist to these guidelines was revealed yesterday (WSJ, subscription):
(Doctor) Michael Fiore is in charge of revising federal guidelines on how to get smokers to quit. He also runs an academic research center funded in part by drug companies that make quit-smoking aids, and he personally has received tens of thousands of dollars in speaking and consulting fees from those companies.


Dr. Fiore, a University of Wisconsin professor of medicine, headed the 18-member panel that created those guidelines. He and at least eight others on it had ties to the makers of stop-smoking products.

Those opposed to urging medication on most quitters note that cold turkey is the method used by the vast majority of former smokers. They fear the federal government's campaign could discourage potential quitters who don't want to spend money on quitting aids or don't like the idea of treating their nicotine addiction with more nicotine.

"To imply that medications are the only way is inappropriate," says Lois Biener, a senior research fellow at the University of Massachusetts at Boston who has surveyed former smokers in her state. "Most people don't want them. Most of the people who do quit successfully do so without them."
What is interesting is the way the government makes these recommendations: based on clinical trials. And who is better equipped to perform clinical trials than drug companies? (Bias 1). Further, all of the individuals in clinical trials must sign consent, and therefore have to be willing to take a drug (Bias 2). So these "clinical trials" are, by their very nature, skewed toward those willing to take a drug.

But in the interest of revealing effectiveness of these smoking cessation drugs in the real world, another type of study, an observational population trial that looks at all comers to the smoking cessation party, found this:
Studies of quitters outside clinical trials have shown no consistent advantage for medicine over cold turkey, the pharmaceutical industry's primary competitor. An unpublished National Cancer Institute survey of 8,200 people who tried quitting found that at three months, users of the nicotine patch and users of bupropion (Wellbutrin) remained abstinent at higher rates than did users of no medication. But at nine months, the no-medication group held an advantage over every category of stop-smoking medicine. The study was presented at a world tobacco conference last summer.
But the potential conflicts with the pharmaceutical industry don't end there:
The American Cancer Society has allowed its logo to be placed on stop-smoking products in exchange for money. A Cancer Society spokesman defends that decision, crediting the pharmaceutical industry for bringing invaluable marketing muscle to the society's Great American Smokeout every November.
Gee, I wonder why. Lots and lots of Wellbutrin and Nicorette is sold each November, I'm sure. Gotta "raise that public awareness" now don't we? It seems personal responsibility has gone out the window.

So smokers, go ahead, pay the drug companies to maintain your oral gratification. But just know what you're getting into. Oh, sure, there's the powerfully addicting nature of nicotine... but isn't that a drug, too?

Maybe before smokers buy the drugs, they should just quit. Do it any way you can - substitute a toothpick for a cigarette - I had one patient who liked dried apricots and sucked on those instead - whatever - just do it.

And see what happens.

Now, if I could figure out a way to bypass that computer prompt...



Judy said...

I had a psych professor who just quit lighting his. Several advantages - cost, for one. He'd puff on a cigarette the entire 2 hours of our seminar, then put it back in the pack for later.

Since he wasn't lighting his, the other smokers were afraid to light theirs, even though the seminar was in an off-campus location and theoretically smoking was permitted.

During the last class, one of my classmates finally asked him why he didn't just light his (expletive deleted) cigarette.

Response: "My doctor told me I was going to die if I didn't stop lighting them."

Worked for him. Definitely cheaper than any of the cigarette substitutes.

Margaret Polaneczky, MD (aka TBTAM) said...

I'm beginning to think that anyone performing drug company sponsored research needs to be taken off any panel making recommendations, especially if they also receive consulting fees or speakers honoraria. These folks have a built in bias.