Published in Australian Doctor, 3 February 2012

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The wrong message

It's crucial to halt the damage done by misleading media reports on quitting.

A RECENT study, claiming nicotine replacement therapy is not effective in a real world setting, has received considerable media attention. 1 Sadly, many of our patients will be influenced by this flawed report and may decide to not use this proven treatment to help them quit.

The study by US researcher Hillel R Alpert and colleagues followed a group of smokers over a four-year period. It compared relapse rates in those who used over-the-counter nicotine replacement therapy to quit vs unaided cessation (Tobacco Control 2011; online). The rate of relapse was the same in both groups, leading the authors to the spurious conclusion that nicotine replacement therapy is ineffective in a real-world setting.

However, the authors have confused effectiveness of treatment with relapse prevention. A huge body of  evidence from randomised controlled trials has confirmed that nicotine replacement therapy (NRT) is effective in helping smokers quit "regardless of setting".2 Moreover, a meta-analysis  of nicotine replacement therapy, specifically in the community setting, found it more than doubled quit rates compared with placebo.3

As the absolute quit rates are higher in the nicotine replacement therapy group compared with the unaided cessation group, and as both groups relapse at similar rates, the final number of long-term quitters is greater in the nicotine replacement therapy group. The correct conclusion from this study is that the treatment worked and that patients later relapsed.

Nicotine dependence is now seen as a chronic, relapsing medical condition and repeated relapses are a normal part of the quitting process. No quit method has an effect on relapse months later.

Another important factor overlooked in this paper is selection bias. It is well known that smokers who self-select to quit with treatment are less likely to succeed than those who choose to go it alone.4  Those who choose NRT have more past failures, higher dependence and lower quit rates. This bias will obviously distort the results in favour of the non-treatment group.

There are other methodological issues in this study that further undermine its scientific credibility, such as recall bias 4and the low 38% overall follow-up rate.

Although over-the-counter NRT is effective, one genuine concern revealed in this study is the poor compliance with its use. This is a strong argument for smokers to see a health professional to optimise therapy. Nicotine replacement therapy is most effective if used for a full course and in combination therapy; for example, nicotine patches plus gum. The PBS listing of nicotine patches gives GPs the opportunity to advise and support their patients to optimise quit attempts. However, there is still a lot of work to do, as many GPs struggle to deliver this extra assistance.

Our greatest concern is that the media reports will further damage our patients' perceptions of nicotine replacement therapy and discourage quit attempts. That would be a tragedy.

GPs should have no hesitation in repeating the advice of the recent Australian smoking cessation guidelines that nicotine replacement therapy is an effective and safe first-line aid to quitting.5 It will work even better if the family doctor invests a little time to support and supervise treatment.



Dr Mendelsohn is a GP and tobacco treatment specialist. He wrote this article on behalf of the Australian Association of Smoking Cessation Professionals.


Dr Mendelsohn has received funding from GSK and Pfizer for teaching, consulting and travel.


  1. Alpert HR. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. 10.1136/tobaccocontrol-2011-050129
  2. Stead LF et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1.
  3. Hughes JR et al. A meta-analysis of the efficacy of over-the-counter nicotine replacement. Tobacco Control 2003;12:21-27
  4. Shiffman S et al. Use of smoking cessation treatments in the United States. Am J Prev Med 2008;34(2):102-111
  5. Zwar N et al. Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners, 2011.
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