John R. Polito

A January 2021 California study published in Urology (PMID 33450283) found that among smokers who attempted to quit within 3 years of being diagnosed with bladder cancer, the "majority (66%) of successful quitters did so ‘cold turkey’ without pharmacotherapy or behavioral therapy."

It found that 115 of 151 active smokers diagnosed with bladder cancer successfully quit. Not only did most attempt to quit cold turkey (63 of 115 or 54%), it generated the lion’s share of the study’s 64 successful ex-smokers (42 of 64 or 66%).

Despite a growing body of population-level evidence shouting otherwise, HHS’s SmokeFree.gov website continues telling smokers that using nicotine replacement therapy "can double your chances of quitting for good."

Entitled "Prevalence and Correlates of Successful Smoking Cessation in Bladder Cancer Survivors," not only did cold turkey prevail over NRT quitters in the Urology study, researchers were surprised to discover that cold turkey clobbered cessation’s gold standard, the combination treatment of behavioral counseling plus pharmacotherapy.

Cold turkey generated 8.4 times as many ex-smokers as counseling plus pharmacotherapy combined, while being nearly twice as effective (66% vs. 36%).

Today, SmokeFree.gov rates "Counseling Plus Medication" four stars (the website’s highest-rated quitting method among the 16 methods listed) while failing to list, rate, or even mention cold turkey.

Cold turkey’s omission exists despite the 2020 acknowledgment on page 15 of the 700 page HHS report entitled "Smoking Cessation: A Report of the Surgeon General" that:

"Proponents of encouraging smokers to quit without treatment, often called quitting "cold turkey," point to data indicating that most smokers who quit successfully do so without medications or any type of formal assistance, as well as to population surveys suggesting that cold-turkey quitters do as well or better than those who use over-the-counter NRTs."

The Urology study’s authors downplay the gold standard's defeat.

"There remains an abundance of evidence that combination treatment (behavioral counseling and pharmacotherapy) is an optimally effective means of smoking cessation," they wrote. "However, where and how these practices fit into the oncology care model requires further assessment."

The scientific foundation for their "abundance of evidence" reference are the studies underlying Recommendation 7 of HHS’s 2008 Guideline Update, which reads:

"7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage ALL individuals making a quit attempt to use BOTH counseling and medication" (see 2008 Guideline, PDF page 7)

The policy claims to be supported by 2008 Guideline Table 6.24, entitled "Effectiveness of and estimated abstinence rates for the combination of counseling and medication versus counseling alone," a table purporting to be backed by 9 studies.

It's a critical evidence table, as it's pharma influence's means of destroying government backing and support for both stand-alone cognitive behavioral therapy programs (CBT) and cold turkey education, counseling and support programs such as those at WhyQuit, Joel's Library, and Turkeyville.

All but one of the following studies (the largest) involved study marketing and/or informed consent followed by randomization, a process that fosters expectations in participants of receiving weeks or months of free nicotine replacement products.

As for the specifics of Table 6.24's nine studies:

1. Fagerstrom 1984 is a totally un-replicable nicotine gum study in which 13 physicians conducted 4 follow-up counseling contacts "in their own personal way";
2. Hall 1985 found that at 52 weeks the difference between intense counseling and intense counseling plus nicotine gum was not significant;
3. Hand 2002 involved 4 weekly counseling sessions and concluded that "in hospital patients NRT, given as regular daily patches plus an inhalator to be used as needed, did not add to the smoking cessation rate achieved at 1 year by regular advice and support ...";
4. Huber 1988 is a German nicotine gum study with no abstract. According to a 2012 NRT Cochrane Review the behavioral arm involved 5 weekly group meetings, there was no cessation validation and quit rates were derived from graphs;
5. Killen 1984 is a small (20-22 per arm) rapid smoking aversion therapy plus nicotine gum study which notes that "Since there was only one therapist per treatment condition it is possible that therapist characteristics may have accounted for differences in outcome";
6. Molyneux 2003 is a "brief counseling" study involving either usual care (nothing), a single 20-minute doctor or nurse session at bedside in a hospital with or without randomization to NRT. As for the quality of counseling, the 12-month continuous cessation rate of the usual care/nothing arm was double the rate of counseling only;
7. Ockene 1991 - The study's 1,286 participants weigh this study heavier than all others combined. That's unfortunate because, according to the study's authors, "The study was not designed to identify the specific impact of the use of nicotine gum." Participants were not randomized to NRT. They individually chose gum use after randomization to either brief quitting advice or brief advice plus 3 monthly 10-minute telephone counseling sessions plus 3 supportive letters;
8. Prapavessis 2006 - CBT counseling actually prevails over CBT + patch (12% vs. 11% point prevalence abstinence at 52 weeks; and
9. Swanson 2003 - Again counseling prevails. Here, at one year follow-up, 180 minutes of upfront quality counseling within the first four weeks, involving the American Cancer Society's Fresh Start program standing alone prevailed (47%) over nicotine patch (20%), bupropion (7%) and patch plus bupropion (27%).

Interestingly, the Urology study references a September 2020 study (PMID 31300827) by some of the UK’s most renowned pharmaceutical industry consultants. The study’s primary finding was that quitting success is positively associated with attempting to quit without cutting down first.

"This study also found no association between quit success and age, time since quit attempt was initiated and use of evidence-based aids ..." "This is contrary to some previous research that found quit success is associated with older age, longer time since quit attempt was initiated, and use of evidence-based aids."

The Urology study found that quit attempts specifically motivated by the quitter's bladder cancer diagnosis were 11.6 times more likely to succeed.

While the diagnosis accelerated attempts and success, it did not alter the quitting methods available. Successful non-cancer quitters evidence similar quitting method selections.

A 2013 Gallup Poll found that 87% of successful ex-smokers didn't use NRT, approved products, or credit being motivated to quit by a smoking-related disease. Most disturbing, after nearly 30 years on the market, just 1% of surveyed ex-smokers credited nicotine gum.

Hopefully, President-elect Biden HHS Secretary nominee Xavier Becerra will remain mindful that America’s leading cause of death during 2020 wasn’t Covid-19 but tobacco.

After four decades of bombarding smokers and doctors with the big lie that nicotine is medicine and its use therapy, the quickest path to national recovery is to begin telling the truth.

If cold turkey is today, already responsible for helping more nicotine addicts arrest their chemical dependence than all other methods combined, imagine the possibilities if HHS begins investigating, teaching, and sharing the keys to successful abrupt nicotine cessation.

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