A recent flurry of provocative headlines was based on a new Massachusetts population study (1), which concluded that "persons who have quit smoking relapsed at equivalent rates whether or not they used NRT." Aside from the inaccurate press coverage, we believe the study's implications aren't justified, or even appropriate, in light of its limitations. In addition, they contradict a large body of previously well-established research.
In our estimation, these are the primary flaws in the study's methodology:
- It's not a controlled study. A population study is good for gauging behavior of a diverse demographic, but is unable to identify all factors which may skew results -- such as differences in smokers' addiction levels, number of quit attempts, type of NRT selected and/or professional support utilized, and so on. In addition, other population studies which reached different conclusions were apparently not considered by the study's authors.
- The follow-up survey response rates weren't high enough. Only about 1/3 of the original group responded to the final population survey—again, making it difficult to identify factors which could or would have affected overall outcomes.
- The NRT-using group was too small. Only 15% of the recent quitter group actually reported using NRT for the recommended length of time, and no determination was made of whether the NRT was otherwise used as recommended (proper dosage, frequency, etc).
- NRT is not a maintenance or relapse prevention aid. It's a short-term tool to increase chances of quitting in the first six months. Long-term quit integrity really relies on whether (and which) maintenance strategies are employed after the quit -- such as peer and/or professional support -- and this study is light on those details.
- The intent of the study is in question. The authors use their findings to advocate more tobacco control funding for large public health programs, which they describe as competing with individual treatment programs, but this study was not designed to compare the cost effectiveness of these two approaches, and did not do so.
The Centers for Disease Control has already officially responded to the study, pointing out that systematic reviews of clinical trials find cessation medications substantially increase 6-month quit rates--which is what they're intended to do. Counseling and NRT are even more effective when combined, and are especially important in helping smokers weather withdrawal during the first few weeks of their quit.
Unfortunately, controversy about the study's NRT conclusions masks the most important takeaway, for tobacco treatment specialists and ex-smokers alike: No matter how you quit, ongoing support and a quit-maintenance strategy are critical for continued smoke-free living.
Alan S. Peters, MTTS; Ann Wendling, MD, MPH
1. Alpert HR, Connolly GN, Biener L. A prospective cohort study challenging the effectiveness
of population-based medical intervention for smoking cessation. Tob Control . doi:10.