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.
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).
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”.