Why Nicotine Replacement Therapy is Not Good Enough

by Ken Derow

Nicotine Replacement Therapy (NRT) is big business. In 2009, it was reported in the book, “World Smoking Cessation Drug Market, 2010-2025,” that annual sales of NRT products (e.g. patches, gums, sprays, etc), was 1.6 billion dollars. It is big business, highly profitable, and is supported by the ever present marketing machine of the big pharmaceutical industry. However, how well does it really work? The answer depends on one’s perspective. While, the purported success rate of NRT therapy by itself is often cited as being about twice as effective as non-assisted smoking cessation (i.e. “cold-turkey”), in fact, this is really only an increase from a level of around 4%-5% to 8%-10%. Is this really impressive? Not if the goal is to dramatically reduce the number of people addicted to cigarettes.

This poor overall success rate shouldn’t come as a surprise. Why should we expect that NRT alone would be highly effective when NRT only directly addresses one of the two key dependencies that make quitting smoking so difficult to achieve. NRT only deals with the physical dependency due to nicotine addiction. The addictive aspect of nicotine is well known, very well established and the assertion that smoking is addictive is not assailable. While NRT helps with the physical dependency, it does not at all address the psychological dependency issues concerning all of the psychosocial cues that frequently trigger the “lighting-up” process. These psychological issues may really be much more intractable and more resistant to treatment than the merely physical addiction issues.

These psychosocial cues are known to all smokers and include such activities, events and circumstances as smoking that is initiated by: having an alcoholic beverage; driving a car; talking on the telephone; going to the bathroom; after a meal; after sexual relations; while watching TV; etc. Many smokers also have their own idiosyncratic cues that are particular and unique to them only, but, nevertheless are just as likely to prompt the smoker to reach for a cigarette.

To be maximally effective and to help reduce the chances of relapsing after initially quitting smoking, a smoking cessation intervention needs to help the smoker disrupt and break both the physical and the psychological dependency issues. A few of the research studies that support these notions follow:

The Cochrane Review study, updated in November 2007, indicates that based on a meta-analysis of many smoking cessation studies, that the quit smoking success rate with NO intervention (i.e. “cold-turkey”) is about 5%, with NRT, it increases by 50%, but, only up to around a success rate of 7.5%. This statistic was based on an analysis of 132 trials covering 40,000 people.

A 2008 review article in the “European Journal of Cancer Prevention,” found that group behavioral therapy was most effective in helping smoker’s quit, followed by the drug burpropion, intensive physician advice, NRT, individual counseling, telephone counseling and nursing instruction. NRT treatment was not the most effective, and in fact, there were three other interventions that were judged to be more effective.

A study issued by the Tobacco Control group in 2006 stated that smoking cessation studies that ended after only 6 months, significantly over-stated the benefits of NRT treatment, as there is a high rate of relapse during the first two years post-quitting. Many studies that quote the quit success rate after a 6-month quit period, or even a 1-year quit period will over-state the real, long-run success rate.

One more important research study was conducted by the “Institute of Social & Preventive Medicine” in Switzerland and looked at all clinical random trials that lasted more than 12 months. There were 12 studies, that averaged 4.3 years in duration, covering 4,792 participants (NRT-2,408, placebo-2,384). There were three types of NRT products included, patch, gum and nasal spray. After 12 months NRT resulted in a doubling of the effective quit rate, but, the absolute success rate was still only 7% of the 2,408 using a NRT product.