Last month, Congress heard testimony about how "Facebook chooses what information billions of people see, shaping their perception of reality," that "they have 100% control over their algorithms," that it's "buying its profits with our safety."

What about Google? Although yesterday Google made headlines for not playing fair in the European Union, what about here in the U.S. when public health, not profits, is the core issue?

According to the Surgeon General, tobacco use is the leading cause of preventable death in the United States and worldwide. While COVID-19 related deaths averaged 35,120 per month during the past 21 months, tobacco-related deaths have averaged 40,000.

Not nearly as innocent as most who contract COVID-19, still, nearly all smokers became addicted to inhaled nicotine while children or teens, with most having little appreciation of what it means to be addicted.

With smoking claiming half of adult smokers, the lifetime struggle for more than 30 million Americans is ending their slow suicide.

What if quitting cold turkey is both more productive and effective in creating ex-smokers than over-the-counter (OTC) nicotine replacement therapy or NRT? And what if Google's search algorithms suppress sites that encourage, teach and support abrupt nicotine cessation, while featuring sites that discourage it?

NRT (Nicorette gum) was first approved by the FDA in 1984. Webster's 1973 definition of "cold turkey" is the "abrupt complete cessation of the use of an addictive drug either voluntarily or under medical supervision."

Cold turkey is, thus, about abruptly ending use of nicotine, not about transferring to new and creative ways to introduce nicotine into the bloodstream.

Contrary to the cold turkey bashing seen in Nicorette commercials, in January 2020, the U.S. Surgeon General reluctantly acknowledged that, at the population level, more smokers successfully quit smoking cold turkey than by all other quitting methods combined, and at rates equal or superior to NRT.[1]

Frankly, the Surgeon General had little choice. In 2002, a California study published in the Journal of the American Medical Association declared that "NRT appears no longer effective in increasing long-term successful cessation."[2]

Back then, population-level quitting method assessments were few and far between. But, to cold turkey's benefit, growing e-cigarette popularity forced researchers to begin examining the e-cigarette's impact upon the dynamics of real-world quitting.

A 2014 Mayo Clinic Proceedings prospective cohort study (co-authored by the UK's leading NRT advocate) found that "use of NRT bought over the counter was associated with a lower odds of abstinence (odds ratio, 0.68; 95% CI)."[3]

Table 7 data from a 2018 study indicated that cold turkey was 3.3 times as effective as NRT and 11 times more productive in generating successful quitters.[4] Table 1 data from a 2020 study found "unassisted" quitting 24% more effective and 4 times as productive.[5]

Most recently, a 2021 study found that 115 of 151 smokers with bladder cancer attempted quitting with most going cold turkey (63 of 115 or 54%), and two-thirds of successful quitters succeeded via cold turkey (42 of 64 or 66%).[6]

As for those plucked and headless turkeys dropping from the sky in Nicorette commercials, a 2013 Gallup Poll asked successful ex-smokers the open-ended question, "What strategies or methods for quitting smoking were most effective for you?"

Talk about frightening, after nearly 3 decades of heavy Nicorette marketing, only 1 percent credited nicotine gum.[7]

Google Experiment

Try this. Pretend that you're a smoker wanting to quit cold turkey and seeking info on the keys to succeeding cold turkey. What search request would you type into Google? What about "quit smoking cold turkey"?

Advertisements aside, the following select quotes are from the top 10 Google "quit smoking cold turkey" search results returned on November 11, 2021. As you read, notice how many sites discourage quitting cold.

1. healthline.com: "cold turkey can seem especially daunting." "There are many nicotine products available to help you wean off nicotine," "Cold turkey is tough." "Without NRT, experts argue the results from trying to "white knuckle it" generally aren't great." "For some people, pairing an abrupt quit date with NRT may increase their chances of staying quit."

2. medicalnewstoday.com: "Quitting cold turkey is one way of stopping smoking. With this technique, people could cease smoking completely without using nicotine replacement therapies (NRTs) such as patches or gum." "A 2016 study [linked] found that cold turkey is more successful than gradually cutting down on nicotine intake." [Note: in the linked study "both groups" "used nicotine replacement before and after quit day"]

3. truthinitiative.org: "Relying on willpower alone, however, is not likely to be successful." "[W]hile some people can quit this way, at least 95 percent of people can't." "Quitting cold turkey has such a low success rate due to the nature of addiction."

4. samhsa.gov: [Returned page does not mention cold turkey]

5. webmd.com: [Google returned a primary and secondary page] Primary page: "2. Cold Turkey" "There's more to it than just tossing your cigarettes out. Smoking is an addiction. The brain is hooked on nicotine. Without it, you'll go through withdrawal." "Ask your doctor about ... medication ..." Secondary page: "Cold turkey (no outside help)." "About 90% of people who try to quit smoking do it without outside support -- no aids, therapy, or medicine. Although most people try to quit this way, it's not the most successful method. Only about 5% to 7% are able to quit on their own."

6. gatewayfoundation.org: "Going cold turkey seems to some like the easiest way to quit smoking. However, there are many drawbacks and dangers you may experience with the cold turkey method." "EFFECTIVE WAYS TO QUIT SMOKING" "1. Nicotine Replacement Therapy"

7. verywellmind.com: "Many people decide to go "cold turkey" when quitting smoking—that is, they stop smoking all at once without medication or nicotine replacement products. Quitting this way isn't easy. While it might work for some people, it's not the most effective method of smoking cessation."

8. nhs.uk: "Going cold turkey may be appealing and works for some, but research suggests that willpower alone isn't the best method to stop smoking. In fact, only 3 in every 100 smokers manage to stop permanently this way. Using nicotine replacement therapy (NRT) and other stop smoking medicines can double your chances of quitting successfully compared with willpower alone."

9. nicorette.com: "Research over the past 25 years has shown that while some people can quit with the cold turkey method, at least 95 percent of people can't. But, using nicotine replacement therapy products can increase your chances of success and help make quitting more successful." "[N]icotine replacement products have been shown to double chances of quitting when measured against a placebo."

10. PubMed randomized controlled trial. "[A]brupt smoking cessation is more effective for long-term abstinence than taking a gradual approach" [when both groups receive 2 weeks of pre-quitting NRT and one group receives] "instructions to reduce smoking by half of the baseline amount by the end of the first week, and to a quarter of baseline by the end of the second week." [Upon quitting] "both groups" [received] "21 mg/d nicotine patches, and the participant's choice of short-acting NRT."

Notice that GlaxoSmithKline, Nicorette's maker, is a top 10 authority on quitting cold turkey (#9), that Google's #4 search result doesn't mention cold turkey, and that two results, #2 and #10, rewrite the historic definition of cold turkey so as to include use of the addictive drug.

And what about Google's #3 result telling smokers that "at least 95 percent of people can't" quit cold turkey when it's how most ex-smokers succeed, or the #8 result declaring that "only 3 in every 100 smokers manage to stop permanently this way?"

An extreme example that's nearly the opposite of Google's featured "95% can't quit cold" and "only 3 in 100 stop this way" claims, a 2006 Australian study of smoking patients of family practice physicians found that cold turkey quitters accounted for 1,942 of 2,207 former smokers, a whopping 88%, and was twice as effective as NRT.[8]

Before being too hard on Google, in fairness, the pharmaceutical industry and its army of paid professor consultants/researchers have owned U.S. cessation policy since June 2000.

Classic bait and switch, pharma and friends get smokers to buy and try NRT by sharing clinical trial efficacy findings when population-level effectiveness studies consistently find OTC NRT ineffective.

The unsolved mystery is, why are the outcomes so different? The most frightening question is, what's the cost of Google actively suppressing the quitter's natural instincts in terms of failed quits and lost lives?

Google's Cessation Understanding

What right do smokers have to expect the Internet's largest knowledge-sharing guardian and librarian to comprehend how and why NRT clinical trial efficacy and real-world effectiveness are nearly polar opposites?

Google should appreciate that quality real-world studies involve snapshots of the entire quitting picture, while randomized clinical trials involve a unique subset of NRT or "medication" seeking quitters willing to postpone and delay their attempt until commanded by researchers to quit.

It's important because it's impossible to randomize spontaneous quit attempts, yet they're up to 260% more effective than planned and delayed attempts.[9] [10]

Common sense tells us that cold turkey quitters -- expecting to encounter, endure and move beyond withdrawal -- don't normally join clinical trials dangling free NRT as study recruiting bait. The only time cold turkey goes head to head with NRT is out in the street.

Should it have been obvious that randomized placebo-controlled trials comparing drug addicts who'd stopped using the addictive substance to those who continued receiving it are apples to oranges nonsense?

Should Google care that placebo-controlled NRT trials were not blind as claimed in that 3 to 4 times as many placebo group members could correctly declare that they'd been given a placebo as guessed wrong?[11]

Do NRT clinical trial efficacy findings measure replacement nicotine's value or simply reflect frustrated and fulfilled replacement nicotine expectations?

Should it trouble Google that the inability to blind experienced quitters was so profound that researchers resorted to the extreme of putting small amounts of unbuffered nicotine in placebo nicotine patches and gum?[12]

Nicotine's roughly two-hour elimination half-life guarantees that cold turkey quitters become 100% nicotine-free and move beyond peak withdrawal within 72 hours, as their brains have no choice but to begin the process of restoring natural sensitivities.

How many published NRT clinical trials failed to mention the use of pharmaceutical industry-provided active placebos, and should their use destroy the right to insinuate that placebo performance reflects the real-world cold turkey quitter's chances ("your chances")?

Should Google care that the intensity of study counseling, the number of participant study contacts, and the amount of contact time significantly inflated NRT efficacy victories, or that the timing and content of counseling/support was designed to foster successful transfer to replacement nicotine, not the needs of the placebo group which was enduring peak withdrawal within 24 to 48 hours of ending nicotine use?

Google's Algorithms

The power to decide which websites are featured and which are discounted, hidden, or suppressed isn't necessarily a bad thing. The problem is that corporations are profit-driven shareholder-beholden entities.

GlaxoSmithKline, Pfizer, and Johnson & Johnson are the primary U.S. quitting product manufacturers, with hundreds of millions in annual corporate giving and consulting fees biasing thousands of individuals and organizations.

Unlike GSK, Pfizer, and all the organizations and websites they help fund, cold turkey doesn't purchase Google advertising.

Corporate morals, if any, rely upon the willingness of a majority of the board of directors to question and, if necessary, challenge the path taken by corporate officers and staff.

And is it fair to expect Google to be a subject matter expert in all fields? Clearly not. But what about in regard to a nation's leading cause of preventable death?

Should the risk of harm, degree of harm, and its preventability determine Google's accuracy burden when deciding which information or websites to feature?

If the quitter's natural inclination is full and abrupt nicotine cessation, if cold turkey is how the vast majority of nicotine-dependent humans arrest their dependence, and if cold turkey is more effective than gradual nicotine weaning schemes, should Google search algorithms support or discourage it?

Given Google's featured "quit smoking cold turkey" search results, is it fair to assert that Google currently discourages our nation's most productive quitting method?

It wasn't always so

As the 1999 founder of WhyQuit, the early years were exciting. By 2001, Google had indexed more than a hundred WhyQuit pages, the site had evolved into the Internet's leading cold turkey destination, and was ranked in the top 10 in nearly all Google "stop smoking" keyword and phrase searches.

By 2019, WhyQuit's collection of Google indexed motivation, education and support pages had grown to more than 1,500 and the site was visited by more than 2 million unique annual visitors.

It was then that websites teaching, supporting and advocating cold turkey experienced huge declines in Google search engine standings.

Today, according to Google Search Console, WhyQuit has "2,149 valid pages," with "74.7% [of] URLs with a good page experience," yet those pages now average less than 200 Google web search clicks per day.

"Joel Spitzer's Stop Smoking Video Library" on YouTube was impacted to a lesser degree (a 48% reduction in views from 2018 to 2020). A cold turkey educator and program director for nearly 50 years, Spitzer's 500 cold turkey quitting videos address nearly every cold turkey quitting topic imaginable.

Turkeyville, a 14,000+ member Facebook education-oriented cold turkey support group, also experienced a noticeable decline in 2019 new member applications.

Needless to say, watching WhyQuit's erasure has been demoralizing. My mentor Joel Spitzer, possibly the world record holder for the most days spent presenting live quitting programs, retired in 2020 after nearly 50 years of service.

WhyQuit has been a Google News contributor for nearly two decades. How visible will this article be after featuring Google's "cold turkey" misinformation? Stay tuned.

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References

1. ↩ USDHHS. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020 (see page 15).

2. ↩ Pierce JP, Gilpin EA. Impact of Over-the-Counter Sales on Effectiveness of Pharmaceutical Aids for Smoking Cessation. JAMA. 2002;288(10):1260–1264. doi:10.1001/jama.288.10.1260

3. ↩ Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world". Mayo Clin Proc. 2014 Oct;89(10):1360-7. doi: 10.1016/j.mayocp.2014.07.004. PMID: 25282429; PMCID: PMC4194355.

4. ↩ Weaver SR, Huang J, Pechacek TF, Heath JW, Ashley DL, Eriksen MP. Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015-2016. PLoS One. 2018 Jul 9;13(7):e0198047. doi: 10.1371/journal.pone.0198047. PMID: 29985948; PMCID: PMC6037369.

5. ↩ Pierce JP, Benmarhnia T, Chen R, White M, Abrams DB, Ambrose BK, Blanco C, Borek N, Choi K, Coleman B, Compton WM, Cummings KM, Delnevo CD, Elton-Marshall T, Goniewicz ML, Gravely S, Fong GT, Hatsukami D, Henrie J, Kasza KA, Kealey S, Kimmel HL, Limpert J, Niaura RS, Ramôa C, Sharma E, Silveira ML, Stanton CA, Steinberg MB, Taylor E, Bansal-Travers M, Trinidad DR, Gardner LD, Hyland A, Soneji S, Messer K. Role of e-cigarettes and pharmacotherapy during attempts to quit cigarette smoking: The PATH Study 2013-16. PLoS One. 2020 Sep 2;15(9):e0237938. doi: 10.1371/journal.pone.0237938. PMID: 32877429; PMCID: PMC7467279.

6. ↩ Bassett JC, Matulewicz RS, Kwan L, McCarthy WJ, Gore JL, Saigal CS. Prevalence and correlates of successful smoking cessation in bladder cancer survivors. Urology. 2021 Jan 13:S0090-4295(21)00047-9. doi: 10.1016/j.urology.2020.12.033. Epub ahead of print. PMID: 33450283.

7. ↩ Gallup Poll, Most U.S. Smokers Want to Quit, Have Tried Multiple Times, July 31, 2013 ↩

8. ↩ Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav. 2006 May;31(5):758-66. doi: 10.1016/j.addbeh.2005.05.054. Epub 2005 Aug 31. PMID: 16137834.

9. ↩ Ferguson SG, Shiffman S, Gitchell JG, Sembower MA, West R. Unplanned quit attempts--results from a U.S. sample of smokers and ex-smokers. Nicotine Tob Res. 2009 Jul;11(7):827-32. doi: 10.1093/ntr/ntp072. Epub 2009 Jun 9.

10. ↩ West R, Sohal T. "Catastrophic" pathways to smoking cessation: findings from national survey. BMJ. 2006 Feb 25;332(7539):458-60. doi: 10.1136/bmj.38723.573866.AE. Epub 2006 Jan 27.

11. ↩ Polito JR. Smoking cessation trials. CMAJ. 2008;179(10):1037-138. doi:10.1503/cmaj.1080096

12. ↩ Polito JR, FDA knew stop smoking product clinical trials not science-based. Feb 2, 2019 WhyQuit

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