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Pfizer’s campaign to drug as many smokers as possible

Pharmaceutical giant Pfizer is in the middle of a major campaign to convince Australian smokers that they should not try to quit without taking anti-smoking medication.

The company sells over-the-counter nicotine replacement therapy (NRT) and prescription drug varenicline (brand name Champix). A Pfizer brochure “what makes you think you can quit this time?” and website stress that “only 3-5% of people who try to outsmart cigarettes without treatment succeed”, that “a serious quit attempt needs a plan” and that most smokers “require help from a health-care professional”.

Each of these claims is highly contestable. Pfizer and other pharmaceutical companies see cold turkey as the enemy of their efforts to medicate as many smokers as possible. Smoking cessation has become increasingly pathologised to the point that public awareness of its natural history has become heavily distorted.

For years, cold turkey has been denigrated as a hopeless strategy and ignored in public campaigns. But ask 1000 ex-smokers how they stopped and you get a very different answer. As occurs with personal efforts to stop problem drinking, gambling and narcotics use, population studies consistently have shown that a large majority of smokers who permanently succeed in quitting do not use any form of assistance.

In 2003, 20 years after the introduction and widespread promotion of cessation pharmacotherapies, those trying to stop in the past year unaided (64.2%) were still twice as many as those using pharmacological aids (32.2%) and only 8.8% of US smokers attempting to quit used a behavioural treatment. Moreover, despite the best efforts of the well-resourced pharmaceutical industry to promote pharmacologically mediated cessation, a large body of clinical trials demonstrating that various forms of pharmacotherapy and other forms of help can significantly improve cessation, the most common method used by those who successfully stop remains unassisted cessation (cold turkey or reducing before quitting).

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”.

Today, multiplying the number of people using a method by the number successfully quitting using it, there is daylight between the number of ex-smokers who have stopped unassisted and the next most common successfully attributed method (nicotine replacement therapy). A 2007 paper in the American Journal of Public Health [97(8):1503-9] showed that of smokers who had quit successfully for 7-24 months, 75.7% had gone cold turkey; 8.6% had cut down then quit and 12.4% had used NRT.

Pfizer’s claim that “most require help” is not only nonsense, but contrasts with a reference it cites  in its own brochure, which states “about one-third of smokers now use a medication when they try to stop”, meaning that two-thirds don’t. Its claim that smokers need a plan is also highly debatable. A recent study (Nicotine Tob Res 2009;11(7):827-32) of unplanned cessation found that unplanned cessation attempts were twice as successful as planned attempts and significantly, that most unplanned quit attempters do not use any assistance.

The emphasis about the futility of people trying to stop smoking unaided acts to exclude popular understanding of what is the most common story of cessation:  doing it without professional or therapeutic help. When citizens have common, ordinary and self-limiting ailments, traits and behaviours constantly redefined as needing treatment, avoidable iatrogenic consequences and burgeoning health-care expenditure can follow. But the steady erosion of human agency and self-belief as people lose confidence in their ability to recover or change unhealthy practices is perhaps of greater concern.

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  • 1
    John Molloy
    Posted Friday, 18 September 2009 at 1:54 pm | Permalink

    I used cold turkey successfully in 1986, four years before my father was diagnosed with the lung cancer that killed him. I had tried unsuccessfully before, but found two things worked for me. Firstly, thinking of smoking as a disease, and that having given up I was a “smoker in remission” . Secondly giving up alcohol for 6 months.

    My son used the medication but found that giving up was “too easy” , and so went back to smoking. 18 months later, he’s trying again. We’ll see.

  • 2
    stephen martin
    Posted Friday, 18 September 2009 at 2:42 pm | Permalink

    Cold Turkey is quite possible if you are motivated to stop. That is, not because you are told it would be advisable, but because there is a very good motive to do so. As with John Molloy I quit smoking after a relative, who smoked 60 cigarettes a day died of lung cancer. My habit was about a packet of cigarettes per day, more though if down the pub for any length of time.
    I had, as with John Molloy, tried several times unsccessfully in the past, for up to about three months at a time. This last attempt was in 1966, I haven’t had a cigarette again; but it was hard, very hard on occasion, particularly when mates tried offering me a cigarette (deliberately) over the odd beer.

  • 3
    David Roberts
    Posted Friday, 18 September 2009 at 3:53 pm | Permalink

    Big Pharma is simply switching addicted smokers to addicted NRT customers. They will of course argue that nicotine without smoke is far less damaging to your health. Sure, but the most successful are people who become non-smokers by actually stopping - “cold turkey” - not just swapping one addiction for another. I find it ridiculous that stopping smoking is even referred to as cold turkey - when a heroin addict or alcoholic’s DTs can be life threatening.

    Re: Champix, it’s worth a look into their initial drug trials to see how much 1 on 1 counselling was involved (which could be a sizable factor in the success rate) after the initial GP consultation. I think they offer a phone number to call here, I’d be surprised if they’d publish figures on how many patients here use the service. Keep in mind the high cost ($ hundreds?) of the drug, which with authority from the GP is put upon the PBS.

    So I guess customers on the smoking, patches, gums, drugs try/fail roundabout are extremely profitable. J&J (which as far as I’m aware own Pfizer) has the market cap. of a small country for a reason.

    Thanks Simon, I get so sick of seeing ads telling everyone how powerless they are, save money and poisons and send them a copy of Allen Carr’s Easyway to Stop Smoking…

    BTW I noticed a settlement btwn Pfizer and the US govt to the tune of billions of dollars last week reported in the Guardian, the whistleblower walked off with something around $50 million. Didn’t get much of a run in our press.

  • 4
    David Roberts
    Posted Friday, 18 September 2009 at 5:22 pm | Permalink

    http://www.guardian.co.uk/business/2009/sep/02/pfizer-settlement-promotions

  • 5
    AR
    Posted Friday, 18 September 2009 at 6:50 pm | Permalink

    Addicts of any kind respond poorly to external pressure, especially when it is coercive, and relapse asap. Like the social workers’ light bulb, it has to want to change and, while difficult, it has the only surety worth a pince, self will, driving.

  • 6
    Scoogsy
    Posted Friday, 18 September 2009 at 11:56 pm | Permalink

    Great article. It’s amazing how we can all be fooled by what we see written on a poster, whether it be a billboard or in a pharmacy.

    I wonder what sort of proof professional pharmacutical companies are asked to provide when making statistical claims in their advertisements - such as “you are likely to be x% more successful using an aid to stop smoking than without”. If what Simon Chapman says is true - it’s blatant lieing and deliberately misleading the public on important health issues.

    I’m not saying I’m surprised, just a little annoyed those sorts of “factual” claims are allowed to be published.

  • 7
    tom cutts
    Posted Saturday, 19 September 2009 at 9:56 pm | Permalink

    I’ve been chewing nicotine gum for the last 10yrs. There’s not a moment in the day (unless im asleep) when i dont have a piece in my mouth. When i quit smoking i was probably on 15 a day and didn’t smoke inside, round the kids etc. Those restrictions dont apply to gum and as such i consider myself far more addicted to nicotine now…..i havn’t had a beer for over a year as whenever i did i’d end up smoking as opposed to chewing mint while drinking (disgusting i assure you). The thought of ‘cold turkey’ now is far more daunting than it ever was while i was actually smoking……..i think these nicotine companies have to be held accountable for, at the very least, harmful false advertising. As some of the others posts said, nicotine replacement therapy does not help people quit at all; it just shifts their addiction to another from one product to another

  • 8
    Liz45
    Posted Sunday, 20 September 2009 at 11:59 pm | Permalink

    I gave up smoking in 1996 - cold turkey. The ‘secret’ for me was my determination, and the motivation was money. I was on a pension and was lying awake worrying about how I’d pay my car insurance, my next electricity bill etc. I’d been sick and realized how dumb it was, having a throat infection and smoking. So, I decided, that when I finished the cigs in the packet, that was it! I wrote the price of the packet on a bright piece of paper, sat it on the chair opposite me, and that was it! It was tough, but I do realize that others do it much tougher than I did. I’ve even heard, that addiction to cigarettes is worse for some people than addiction to heroin. Scary?I even hate the smell of cigarettes now. Before smoking was banned in clubs, I couldn’t even go to the meat raffle, as I’d come home with red eyes, smelly hair and clothes - from other peoples’ cigarettes.

    Pharmaceutical companies like cigarette companies need to be taken to court and face charges of using peoples’ addiction to make their millions. I find their behaviour reprehensible and disgraceful. I think the secret to giving up is motivation, commitment and determination - or in my case, pure stubborness! I’ve lost 2 extended family members to lung cancer in 9 months - they’d both given up too! That scares me. I’d like stronger laws against these peddlers of death prevented from selling their wares, particularly to young people. I feel very upset when I see young people smoking. What a waste! Particularly young women, who may want to be mothers one day. I didn’t smoke heavily when my kids were little, but I do feel guilty that I did. We weren’t warned of the dangers in the 1960’s - sad but true!
    To those of you who want to quit, just get real mad with yourself, and hopefully, someone who will support you through the hard bit. Have a goal of what to do with the money - some goal is a good idea - a trip! I think of the money I’ve saved - I couldn’t afford to buy food and petrol these days if I still smoked!

  • 9
    JohnRPolito
    Posted Monday, 21 September 2009 at 9:54 pm | Permalink

    Thank you Professor for this important article. The pharmaceutical industry has attempted to define it’s primary competitor as not only abrupt nicotine cessation but attempting to stop cold turkey without any dependency education, counseling or support. I mention this because although I think your contention would be that statistics show that surprisingly few cold turkey quitters seek education, counseling and/or support, mine is that it affords tremendous potential to dramatically increase cold turkey success rates and as yet there has never been an honest national attempt to teach those dependent upon nicotine the “Law of Addiction.” Smokers don’t need to come to us. Teaching them where they now find themselves makes the quitting rules simple: just one puff of nicotine when quitting and the brain will soon be begging for more.

    I’d also encourage you to begin challenging researchers on whether their 26 years of placebo controlled pharmacology trials have any foundation whatsoever in science. Duke’s Jed Rose, co-inventor of the nicotine patch, recently published a pre-cessation patch use paper in which 4 times as many placebo group participants correctly determined their assignment as got it wrong. Professor, name any other pharmacology study area where no participant is experiencing the condition sought to be treated (withdrawal) until researchers command its onset. It is outright fraud to suggest that a nicotine addict with a significant quitting history will not quickly recognize the onset of full-blown withdrawal. These studies document assignment awareness frustrations not efficacy. Thanks again.

    In no area has the placebo sham been more pronounced that with varenicline (Champix/ Chantix). What’s different with varenicline is that blinding fails for 1st time quitters too, as the expected dopamine “aaah” sensation following a puff of nicotine no longer arrives. I’m of the opinion imposing massive corporate fines won’t change things. Pfizer executives need to start getting jail time. History will record pharmacology cessation researchers as either having been extremely stupid or criminally culpable in the deaths of hundreds of thousands of smokers.

  • 10
    Frank Pilling
    Posted Thursday, 24 September 2009 at 11:03 am | Permalink

    Prof Chapman presents the ‘evidence’ for the success of cold turkey, but limits all his comments to ex-smokers who have successfully quitted, ignoring all those that did not successfully quit. Of course if you ignore all the failures you will get a good-news story. Given the vast majority of people try to quit cold turkey, its obvious that the majority of people who successfully quit will have done so by cold turkey. What about those that did not successfully quit? Professor Chapman states that the most common method is cold turkey (which we already know), but makes no mention of the relative effect of each intervention - which is surely what you want to know if you are trying to quit. What are my chances of success, and how will an intervention, whether conselling, quitline, NRT or therapy, improve my chances?

    His comments suggesting that cold turkey is successful are really only comments showing that most people try via cold turkey (“of smokers who had quit successfully for 7-24 months, 75.7% had gone cold turkey; 8.6% had cut down then quit and 12.4% had used NRT). Yes we already know that’s how most people try. Note the line ‘of smokers who had quit successfully’, again ignoring those that were not successful.

    Finally, the recent study of unplanned cessation showing that unplanned cessation attempts were twice as successful as planned attempts. In this study, those making an unplanned attempt were less dependent on nicotine - so not surprising that they were more successful. (The study reported that those who made an unplanned quit attempt were more likely to report smoking their first cigarette of the day more than 30 min after waking. This is one of the strongest indicators of level of dependence). It’s also pretty obvious that an unplanned attempt would be less likely to include any assistance.

    For an article promoting cold turkey over other interventions there is essentally no information apart from the fact that most people try via cold turkey.

  • 11
    JohnRPolito
    Posted Thursday, 24 September 2009 at 7:58 pm | Permalink

    Mr. Pilling suggests that little or no real-world effectiveness evidence exists to support cold turkey being superior to other quitting methods. I submit that almost every real-world measure taken has proven cold turkey equal or superior in effectiveness, as well as vastly superior in productivity. The US National Cancer Institute’s 2006 survey of 8,200 smokers found that at 9 months that while 16% of non-pharmacology quitters were still quit only 14% of nicotine patch, gum, lozenge and Zyban quitters were still free, and this is one of the most conservative such findings. Take a look at 1 year rates from UK NHS quit smoking services as reported by Ferguson, or read the May 2006 Addictive Behaviors study entitled “Smoking status of Australian general practice patients and their attempts to quit.” In the later cold turkey quitting rates were twice those of pharmacology.

    Would you not agree, Mr. Pilling, that it’s outright fraud for the pharmaceutical industry to suggest to smokers that quitting cold turkey is nearly impossible, that you have to be a super hero to succeed? Is it your assertion that the industry’s false representations are excusable because there may possibly be a subgroup of quitters for which pharmacology is in fact more effective?

    But pharmacology’s sham isn’t just in how its represented but how the study game is played. Would you agree, Mr. Pilling, that it’s probably impossible to blind smokers with significant quitting histories as to the onset of full-blown withdrawal? Efficacy measurement, Mr. Pilling or a reflection of participant expectations?

    Regarding unplanned attempts being twice as likely to succeed, you award full credit to the depth of dependency without sharing actual figures. You need to keep in mind that both Ferguson 2009 and West 2006 involved papers written by acknowledged pharmacology stakeholders. Instead of blind acceptance of their spin look closely at the numbers. While there was a 12 percentage point difference in time to first cigarette, in Ferguson the number of cigarettes smoked per day were 18 among unplanned quitters and 19 per day among planned quitters. Is it really your contention that unplanned quits were 2.6 times greater at 6 months because of a variance in level of dependence? If the study’s authors felt that time to first cigarette had an impact on outcome don’t you think they would have mentioned it either in their findings or discussion? Maybe I missed it. Could you quote their concerns for me? Thanks.

  • 12
    Frank Pilling
    Posted Thursday, 24 September 2009 at 9:31 pm | Permalink

    Well no I didn’t say that ‘little or no real-world effectiveness evidence exists to support cold turkey being superior to other quitting methods’. What I said was that if you are going to talk about cold turkey and other interventions, it would be useful to get some idea of the relative effectiveness of each, rather than comment on how, among the group of successful quitters and ignoring the failures, each smoker quit.

    In any case its perhaps a little irrelevant to talk about relative efficacy of cold turkey vs other interventions, because I agree its absolutely reasonable that you would try cold turkey first. It’s what I would do if I wanted to quit smoking – my initial attempt would probably be to just stop with no other intervention.

    The question would be, what would I do if my quit attempt failed? From the data Mr Polito cites, after 9 months of attempts to quit via cold turkey, a massive 84% had resumed smoking, a figure that would of course increase as time went on. So it’s a pretty significant group we’re talking about here.

    What does that person do? Just try to quit via cold turkey again? Or try counselling, or try NRT? That’s when you need some idea of what is available, and how different interventions might increase your chances of success.

    My understanding is that the pharmaceutical industry promotes its products to those patients who have previously failed a quit attempt. I did not know that they “suggest to smokers that quitting cold turkey is nearly impossible”, and would be grateful if Mr Polito could cite the source of this claim.

    Regarding the data on unplanned attempts, I’m actually not sure what the point of this arguement is – that you shouldn’t plan your quit attempt because if you do you will reduce your chances of success? I do know that number of cigarettes is not necessarily a good indicator of dependence (more dependent smokers just ‘work’ each cigarette harder), and that time to first cigarette is a more reliable indicator of dependence.

  • 13
    JohnRPolito
    Posted Friday, 25 September 2009 at 1:11 am | Permalink

    Most of the great marketing slogans are no longer visible on the net, Mr. Pilling. My favorite was a Nicorette ad that suggested that when going cold turkey you had to be a super hero to succeed. I’m not sure whether or not links are permitted here on Crickey but I’ll try:

    This first one is for the GSK Commit nicotine lozenge and states: “According to one study, 90 percent of “cold turkey” quitters start smoking again within six months.”

    http://www.commitlozenge.com/Nicotine_Cold.aspx

    Notice what GSK doesn’t tell readers, how well OTC NRT products perform at 6 months. Interestingly, this patch and gum OTC study by GSK consultants found just a 7% six month This is a link to its full-text:

    http://tobaccocontrol.bmj.com/cgi/content/full/12/1/21?ijkey=5.ko5/Oz4yutI

    Numbers flim flam, an unfair and deceptive trade practice or outright fraud, take your pick!

    At this link Pfizer asserts that only 2.5% of cold turkey quitters succeed for 1 year:

    http://www.pfizer.ca/english/newsroom/press%20releases/default.asp?s=1&releaseID=113

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