NRT vs Cold Turkey

Nicotine Replacement Therapy = NRT = the patch, lozenge, gum, inhalator. Nicotine is delivered through another (slower) means, satisying the chemical dependency. Originally developed for the Swedish Royal Navy to prevent cravings whilst away at sea, pharmaceuticals soon grasped the opportunity for making $billions by packaging the product as a quit-aid.

In 2006, the NHS spent £48m on prescribing NRT in the community, provided further NRT or prescriptions for 88% of smokers attending the stop smoking services, with the public also spending another £50m on over-the-counter NRT.

Does it work? The research shows an effectiveness rate of only 17%. The placebo control group also had a 10% success rate – meaning that above placebo, NRT has only a 7% success rate. Or a 93% failure rate. Another way of looking at it, is that over half of the effectiveness of NRT is down to subjective psychology. Of that 7%, 2% of patch users are still using it one year later – i.e. they’re still addicted to nicotine (and 13% of the faster-hitting inhaler are still using it one year on).

NRT might replace the device for delivering nicotine, but it doesn’t replace the actual nicotine. It is nicotine – the same addictive substance. It’s also not wholly accurate to call it therapy. They were designed to simply take the edge off cravings for people who couldn’t smoke, but they don’t do anything to the beliefs, perceptions, attitudes and associations around the smoking addiction.

So why is NRT so overrated?

1. Because it seems like a simple solution to a very complex problem.

The sheer convenience of buying something over the counter, or having it prescribed, is another excuse for not having to think too much about it. Its easier for NHS smoking advisors to hand out drugs and hope for the best than invest in psychology, CBT or counselling training to combat nicotine addiction. The rationale is that psychological techniques don’t have the evidence (they actually do, its just that the pharmaceutical industry is much more powerful, can influence the medicine industry and pump £millions into biased talks, advertising and plugging their research). Fortunately, most GPs recognise the need for behavioural support alongside NRT: “…the effectiveness of NRT was seen as critically dependent on behavioural support for smoking cessation. This dependence appeared to be influenced by perceptions that without support smokers would neglect psychological aspects of smoking and use NRT incorrectly”.

2. Because health professionals and decision makers make the mistake of thinking the placebo control group is the same as ‘going cold turkey’.

One of the biggest misinterpretations of the 17% study is that because the NRT was almost twice as effective as the control, this means that NRT is twice as effective as going cold turkey. Here’s something they don’t realise: a placebo control group is not the same as going cold turkey. Cold turkey does not involve sticking on a plaster, and believing it to contain nicotine when it obviously doesn’t (the brain can tell the difference, its addicted to the stuff). The NHS are in danger of totally undermining the potential power of going cold turkey in the right way. Stop Smoking Advisors are actually trained to tell interested quitters that “nrt will double your chances of success”. This is a total statistical error – and possibly consumer fraud. There is no way of knowing whether the smoker could have quit without NRT, and they aren’t given the chance to explore other channels. Instead they are told to put their faith in a drug which only has a 7% success rate.

3. Because NRT can be used to stop smoking for 2 weeks, which is all the NHS needs for a ‘quit’.

The NHS has boasted up to 55% quit rates by prescribing NRT or Buproprion to smokers. What they don’t tell you is that of those who do quit in the short term, after 1 year only 7% to 15% (a study of the UK services) are likely to still be quit. Thats quite a relapse rate. Of people quitting ‘cold turkey’ (or without NRT), 25% were still successful quitters after one year.

The Power of Placebo

Companies like Pfizer are happy to shamelessly attack cold turkey methods of quitting. Pharmaceuticals and the NHS frequently mention ‘statistics show that cold turkey only has a 3-5% success rate’ yet I couldn’t find a single study. In many ways its impossible to test – because the knowledge of being involved in a test is likely to introduce confounding variables that would affect the motives of anyone who is quitting cold turkey. And yet thousands do every day – an Australian study find that in over 2000 ex-smokers, 88% achieved success through cold turkey. So what tests are the NRT pushers using for cold turkey rates, where are these 3-5% statistics? They are actually using the placebo groups – again making the mistake of equating a placebo with cold turkey. They are totally different – different motives, different beliefs about what is going on.

Yet – if they are going to equate cold turkey with placebo – lets find some more interesting ‘placebo’ quit rates. For example, a study of Varenicline showed that in the placebo group, 17.4% were successful after 4 weeks, and 8.4% after a year. This is higher than the effectiveness of NRT! Why was the placebo condition so high in this study? Because participants recieved behavioural support and regular contact sessions.

The people pushing these studies, and the decision makers believing them are overlooking the fact that even placebo – the power of sheer belief coupled with the encouragement and motives of the study (e.g. perks of free products, expenses, being fussed over) – is actually working.

Cold Turkey

The point is that ‘cold turkey’ is very subjective. It includes everyone who half-heartedly tries to pack it in and then lights up the next hour, as well as those who make a determined effort, perhaps seek self-help material, and succeed. Some smokers who think about quitting cold turkey simply lack the resources to know what they are in for, and what could actually be done to enhance the quit.

Whatever yo do – if you are thinking about quitting smoking and don’t feel 100% confident that you can, then seek support of one kind or another. Don’t just ‘hope for the best’ and start smoking again – make sure you stay committed. Don’t believe anyone – especially the NHS – who tell you that you can’t quit on your own because you can. On the other hand, don’t believe that NRT will ‘make you quit’ because it won’t. Do whatever it takes to reach that 100% confidence level – then quitting becomes a lot easier and any cravings will seem insignificant. You need that 100% ‘click’ moment where your whole perception changes (which is what we strive to achieve in the Quit Smoking sessions).

And finally…

Something to think about…

Research carried out by Dr Taylor at Exeter University gives evidence to the strong effects of exercise on reducing cravings and prolonging quit attempts: “If we found the same effects in a drug, it would immediately be sold as an aid to help people quit smoking”.

11 Comments

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  • It is logical to assume that if a smoker can address the other issues of their tobacco addition (a cigarette with coffee, when on the phone, after meals, when stressed, etc.) without the physical urge sabotaging their efforts, and then slowly weaning off the nicotine (clean nicotine without the 40 carcinogens drawn deep into the lungs), they would have much greater chance of a successful quit.

    I don’t trust Big Pharm, but I do believe in logic.

  • I agree with one of the last points made. You have to reach that %100 confidence level to make quitting easier. I think that is why they tell you to pick a quit date. I remember the day I quit I said to myself I can beat this monster. I looked at it in a competative kind of way. I tried to look at the cravings like a person your competeing against taunting you that your going to loose. Or basically trash talking. When I looked at the cravings in that way it boosted my confidence to say to my cravings,”$%^$ you your not gonna beat me!”

  • Sounds logical Sue, but that’s complete rubbish. People only smoke to get nicotine. Nicotine withdrawal is really nothing at all as long as your head is straight.

    People should stop being babies and expecting everything in life to be easy. Don’t take NRT, you got yourself into the smoking trap, grit your teeth for two days and the nicotine leaves your system. Cheaper and less painful than dragging out your addiction for months.

    I quite smoking 3 months ago – 40 a day to nothing. Withdrawal wasn’t remotely painful, I just didn’t want to smoke any more and I figured any suffering I got as a result I deserved. Turned out to be nothing at all.

  • You never mention what the success rate is for cold turkey, Is the success rate lower or higher for cold turkey?

  • I have quit smoking with and without NRT. 4 years ago with NRT and more recently, cold turkey. In my experience, cold turkey is by far the easier route. You give up nicotine once. Lots of fluids, sleep, a headache tablet or two and 72 hours later, you’re through. Whether you are on NRT or not, you will still have cravings. Rather deal with these cravings without nicotine in your system because sooner or later you will have to give up the NRT and that is where a lot of people falter and go back to smoking.

  • Good article. Points about confounding placebo with cold turkey by pharma are well taken. I quit 20 years ago after smoking for 14 years. I began suffering from asthma which provided a strong motivation. I also enjoy cycling and used this as a combination of a replacement and a positive reinforcement. The first three days were difficult. The next 4 weeks, less so, but I remained vigilant. After that a longer ascent towards strength and health, punctuated by the odd “smoking nightmare”. What I learned is that motivation, both towards a goal and away from ill effects is more powerful than nicotine addiction.

  • I tried NRT on my first three quit attempts. It was horrible. Although the NRT did dampen the cravings, the cravings never went away due to the steady supply of nicotine. These ongoing medium level cravings were quite tortuous and madenning, and I relapsed each time after several months.

    Then I tried cold turkey. It hurt a little more at first, but quickly became much easier. I’ve been quit for 2 years now thanks to the cold turkey method. I no longer think about cigarettes even whilst drinking alcohol.

    In my experience cold turkey is much much easier and on the whole. I recommend it to anyone who wants to quit.

  • I quit for 9 months a few years ago after using patches and am now on day 5 of non – smoking again. I used patches the first 4 days and today have decided to scrap the patches and try cold turkey. I would just like to say that this is a great article, the best I have come across. It is very reassuring and motivating as I was in two minds about re – applying the patch as struggling. This article has given me the confidence to remain cold turkey (other than all the other articles I have just read discouraging cold turkey).
    Thanks again, I feel this literature is just what I needed to hear (or read!) and I SHALL do it 🙂

  • Good one, I quit 20 days back, 20 per day to none. It took me really long time to reach here. Tried many things, NRT chewing gum, the patch, and yes few time while in sweden got fascinated with swedish snuss and way swedish stopped smoking using same.
    At the end none worked becuase NRT or Snuss its all about replacing one with other, not quitting. Its as good as saying i stopped drinking where i used to drink 5 peg whisky daily, now i take just few bottles of beer !!!
    Dont fool yourself, quit cold turkey, thats the only way to get rid, you are not fighting to cigerate as a stick alone, its the nicotine. Getting nicotine in any other form and saying you quit is fooling yourself. Cold turkey is not that difficult, its just 3 days, then all go good. Only issue none make money in this. All the best.

  • That is interesting, I’m about to embark on, what I hope to be my final quit and was considering NRT…last quit was cold turkey.
    14 days with NRT is not a quit cos you’re still using nicotine.
    That last bit about exercise has made my mind up, its going to be cold turkey again.

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