Rapid Responses to:

Robert West and Taj Sohal
"Catastrophic" pathways to smoking cessation: findings from national survey
BMJ 2006; 0: bmj.38723.573866.AEv1 [Abstract]
*Rapid Responses: Submit a response to this article

Rapid Responses published:

[Read Rapid Response] How to use behavorial findings to sell NRT
John R. Polito   (28 January 2006)
[Read Rapid Response] Let's have an independent review of smoking cessation services in the UK
David F Marks   (29 January 2006)
[Read Rapid Response] Quit now!
James S Smeltzer, MD, FACOG   (31 January 2006)
[Read Rapid Response] �Catastrophic� Interpretations
John A Stapleton   (31 January 2006)
[Read Rapid Response] Drawing unwarranted conclusions
Robert West   (1 February 2006)
[Read Rapid Response] Carpe Diem
Stevie M Gamble   (1 February 2006)
[Read Rapid Response] Misinterpretation of West & Sohal
Saul Shiffman, Jack E. Jenningfield, Ph.D. Sidney H. Schnoll, M.D., Ph.D.   (3 February 2006)
[Read Rapid Response] Setting Quit Dates
Joel Spitzer   (7 February 2006)
[Read Rapid Response] Market Segmentation
Peter D Singleton   (7 February 2006)
[Read Rapid Response] the ethics of banning smoking
A Larbi   (7 February 2006)
[Read Rapid Response] Re: Setting Quit Dates
Joan McClusky   (8 February 2006)
[Read Rapid Response] Flawed reasoning
Kevin R Lewis   (10 February 2006)
[Read Rapid Response] In Search Of Catastrophes
James O Prochaska   (14 February 2006)
[Read Rapid Response] More misunderstanding
Robert West   (15 February 2006)
[Read Rapid Response] Health insurance coverage for smoking cessation treatment
Hiroshi Kawane   (24 February 2006)
[Read Rapid Response] The theory is pragmatic - now we need a practical application
Andrew J Ashworth   (25 February 2006)
[Read Rapid Response] There is no need to re-invent this particular wheel.
Peter O'Loughlin, Robert West, Taj Sohal   (27 February 2006)
[Read Rapid Response] Who is afraid of doing so?
Ben P Ponsioen   (28 February 2006)
[Read Rapid Response] Recollection Bias?
Corinne A. Keet   (3 March 2006)
[Read Rapid Response] Possible (non-catastrophic) errors in Table 2
Salaheddin M. Mahmud   (9 March 2006)
[Read Rapid Response] Re: Possible (non-catastrophic) errors in Table 2
Robert West   (12 March 2006)

How to use behavorial findings to sell NRT 28 January 2006
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John R. Polito,
Nicotine Cessation Educator
1325 Pherigo Street, Mount Pleasant, SC USA 29464

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Re: How to use behavorial findings to sell NRT

Professor West, your presentation was pure science until you decided to taint and transform a stages of change rebuke into an NRT sales pitch, based upon beliefs that are very likely as erroneous as those you just debunked.

I am at a loss to understand why you felt the need to convert a behavioral finding into a nicotine patch commercial. Such boldness and tenacity after openly declaring your pharmaceutical financial ties is disburbing. I submit that this study should have stood on its own.

Professor West, the following issues beg research attention but it is not in the pharmaceutical industry's financial interests to do so. I submit that the following six conclusions are correct and challenge you to disprove them.

1. Almost all successful UK and US quitters who have remained 100% nicotine free for at least six months quit smoking cold turkey (80 to 90%). Conclusion: Pharmaceutical industry commercials and literature which continue to suggest that quitting cold is nearly impossible are both false and deceptive.

2. Conclusion: Placebo controlled NRT clinical studies were not "blind" as claimed and their conclusions simply cannot be accepted as science-based, especially in light of the fact that NRT has failed to show any advantage whatsoever in all real-world surveys to date (see Mooney M, et al, The blind spot in the nicotine replacement therapy literature: Assessment of the double-blind in clinical trials. Addict Behav. 2004 June;29(4):673-84 and http://whyquit.com/pr/051904.html ). Nicotine is a psychoactive chemical producing alert dopamine/adrenaline intoxication. Any smoker with a quitting history has some degree of awareness of what it feels like to have their nicotine removed and returned.

3. Conclusion: NRT clinical odds ratio victories over placebos were not earned but by default. A significant percentage of the active group had its expectations fulfilled and remained to benefit from study behavioral elements that ranged from telephone contact, evaluation visits, counseling, education and group or individual support, each of which have their own proven efficacy. A significant segment of the placebo group had its expectations of receiving weeks or months of free nicotine products shattered and "most" placebo group quitters dropped out within the first two weeks. In no clinical NRT study did researchers ever interview the majority of placebo group which relapsed within the first two weeks, while this group's assignment beliefs and relapse motivation memories were still fresh and accurate (within the first month).

4. Nearly half of all smokers have now attempted quitting with over -the-counter NRT products. Acknowledged GSK consultants conducted a meta- analysis of OTC patch and gum studies and found that 93% of users had relapsed to smoking within six months (see Hughes, JR, Shiffman, S, et al.,A meta-analysis of the efficacy of over-the-counter nicotine replacement. Tobacco Control, March 2003;12:21-27 ). Conclusion: Athough one year OTC NRT cessation rates are a well kept industry secret, if historic rates from 1 year clinical studies hold, roughly 96% of those using OTC NRT as a stand alone quitting tool relapse to smoking within one year.

5. Only two nicotine patch studies have examined the odds of success of second-time nicotine patch users, Tonnesen (April 1993, Addiciton) and Gourlay (1995 August BMJ). In Tonnesen 100% of second-time users relapsed within 6 months and in Tonnesen the rate was 98.4%. As the NRT quitter use rate continues to climb this factor grows even more critical, yet remains undisclosed by the pharmaceutical industry or its army of consultants. Conclusion: Unlike with cold turkey quitting where the odds of success increase with each subsequent attempt, the repeat NRT user's odds of success dramatically decline.

6. One last NRT point relating to the December 2005 report to the UK government that you co-authored, which led to a government brochure for pregnant mothers which advises "Ideally you should try to give up smoking without the use of NRT but if you can't manage this, you can use NRT. The risks to your unborn baby are far less than from continuing to smoke. If you have sickness or nausea NRT patches may be preferable to gum, lozenges, tablets or inhalers."

According to Dr. Theodore Slotkin, one of the leading nicotine toxicologists, "there is abundant evidence that the major problem for fetal development is exposure to nicotine rather than other components of cigarette smoke." Dr. Slotkin pointed me to the Sarasin study which found fetal rat brain nicotine concentrations 2.5 times higher than the mother's blood nicotine level when on continuous nicotine feed, such as would be the case with the nicotine patch (see Reproductive Toxicology, 2003, 17: 153�162 ). Conclusion: UK fetal development is about to experience its darkest era ever. Oh how I pray that you are right and that the world's leading nicotine research toxicologists are wrong.

In closing I ask you to ponder the impression this study leaf with readers. You identified 996 successful ex-smokers and your lead closing recommendation was the nicotine patch. What would you expect them to believe? If you have survey data indicating how the 996 quit I challenge you to share it here. I submit that it will show that more than 900 of them succeeded without resort to replacement nicotine.

John R. Polito Nicotine Cessation Educator

Competing interests: Editor of www.WhyQuit.com, the Internet's leading abrupt nicotine cessation resource.

Let's have an independent review of smoking cessation services in the UK 29 January 2006
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David F Marks,
Professor of Psychology
City University, London

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Re: Let's have an independent review of smoking cessation services in the UK

West and Sohal�s interesting data lead them to conclude that fundamental changes should be considered in public health campaigns to support quitters. They argue that campaigns should focus on �creating motivational tension�, �triggering action in smokers who are on the �cusp� of a change�, and �immediate availability of treatment such as nicotine patches and counselling to support those attempts, including attempts that were started before help was sought.� It is curious that they do not mention the most effective method of quitting smoking, cognitive behaviour therapy.

I agree with them that changes in the approach being used to support smokers are necessary. However I do not agree that catastrophe theory would be a good working model for improving the service. The currently available NRT-based service was introduced ahead of evidence on effectiveness and cost-effectiveness 1. Now that evaluation evidence actually exists 2, there are reasons to believe that a strategic error was made and that NRT is not as good a working model for long term behaviour change in smokers as the guidelines originally suggested.

To the best of my knowledge no randomized controlled trials have been carried out on the effectiveness of NHS smoking cessation services. The principal evaluation work has consisted of an observational study 2. This study found that one user in seven (14.6%) could be CO-validated as a successful quitter at 52 weeks. At 52 weeks those with lower socio- economic status were least likely to succeed with abstinence rates of only 8.7- 9.8%. Of significant interest, only 15.2% of quitters who had used NRT were abstinent compared to 25.5% of those using willpower or non-pharmacological methods. Self-reported abstinence rates were higher than the CO-validated rates and were unreliable as people tended to exaggerate their success in quitting.

The evaluation of the NHS smoking cessation service showed that quitters using NRT had a 10.3% reduced chance of a successful outcome at one year compared to non-NRT users. RCTs carried out with cognitive behaviour therapy with disadvantaged groups have found one-year CO-validated abstinence rates that were 2-3 times higher than the rates observed in these more recent studies of the NRT-based services of the NHS 3,4,5

West and Sohal�s concluded that almost half of all self-reported quit attempts are made without previous planning and that these unplanned quit attempts succeed for longer. At face value, these findings create a problem for the stages of change model and any other system for supporting quitting that entails planning changes ahead of actually making them. The NHS smoking cessation service is based on the use of NRT within a sequence of planned stages.

West states that he has �done paid research and consultancy for, and received hospitality from, manufacturers of smoking cessation drugs.� Unfortunately his conclusions show a bias towards opinions that are favourable towards the continued use of NRT even though the research evidence cited here, including his own, is unfavourable. West advocates an approach based upon a spontaneous/impulsive decision to quit. But does this �non-method� really introduce a greater chance of success than a structured approach which includes different stages and a considered decision?

W & S�s findings are difficult to interpret because they did not actually observe any quit attempts. They used self-reports of changes made up to five years previously. Such reports are notoriously unreliable because of faulty memory, recency or primacy effects, self presentation/exaggeration effects and other such biases.

The authors� discussion unfortunately borders on the illogical. They state: �These findings do not necessarily imply that planning quit attempts is counterproductive.� Then they notice a contradiction and say: �use of behavioural support and nicotine replacement therapy are known to improve the chances of success even though they generally require planning ahead.� So which is it: does planning (with or without NRT) help or hinder quitting?

There are many reasons to call for an independent review of the NHS smoking cessation service:

(i) the poor outcomes obtained, especially for people from disadvantaged backgrounds, ethnic minorities, pregnant women and young people 2; (ii) the fact that significantly better outcomes could be achieved with another approach such as cognitive behaviour therapy 3,4; (iii) the fact that significantly higher cost-effectiveness could also be achieved with cognitive behaviour therapy 3.4; (iv) the potential for abuse and adverse consequences of over-the- counter NRT 6 ; (v) the fact that one form of an addictive substance (nicotine in smoke) is substituted by or added to another (nicotine gum, patches, lozenges etc); (vi) the setting of excessive targets by the Department of Health leading to demoralization, burn-out of front-line staff, and alleged inflation of numbers of quitters.

1 West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000;55:987�99

2 Ferguson, J, Bauld, L, Chesterman, J, Judge,K The English smoking treatment services: one-year outcomes. Addiction 2005; 100 (s2): 59-69.

3 Sykes, CM, Marks, DF Effectiveness of a cognitive behaviour therapy self- help programme for smokers in London,UK. Health Promotion International, 2001; 16: 255-260.

4 Marks, DF, Sykes, CM Randomized controlled trial of cognitive behavioural therapy for smokers living in a deprived area of London: outcome at one- year follow-up. Psych Health & Med 2002;7:17-24.

5 Marks, DF Overcoming your smoking habit. Robinson 2005

6 Klesges, LM, Johnson, KC, Somes, G, Zbikowski, S, Robinson, L. Use of nicotine replacement therapy in adolescent smokers and nonsmokers. Arch Pediatr Adolesc Med. 2003;157:517-522.

Competing interests: I am a Chartered Health Psychologist. I have never knowingly accepted funding, �free� lunches, or other favours from the tobacco or nicotine replacement (NRT) industries. I advocate the use of evidence- based cost-effective interventions to help smokers quit, including methods other than NRT and am the author of "Overcoming Your Smoking Habit" a cognitive behaviour therapy approach that produces significantly higher quit rates than NRT and impulsive quitting using willpower.

Quit now! 31 January 2006
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James S Smeltzer, MD, FACOG,
Physician, Consultant
Wellstar Health System, Marietta GA USA 30060

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Re: Quit now!

As I counsel pregnant women to quit smoking, I have observed that the persistent quit rate always seemed high - higher than published rates - among those who were ready to "do it" the day of the encounter, including many "surprises" who did not seem ready to do so, but did anyway.

Similarly, the rates of success among those making a commitment but not stopping that day, have seemed lower than the literature would have led me to expect.

The present article calls into question the "standard" conceptualization of three-phase cessation, and lends support to the approach I used to use of "Are you ready to do this today?!"

It would be nice to know with certainty that the same results applied to quits that started in the MD's office.

Competing interests: I assist pregnant women in quitting somking, and have published on NRT use in pregnancy.

�Catastrophic� Interpretations 31 January 2006
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John A Stapleton,
Senior Lecturer
Institute of Psychiatry, London, Se5 8AF

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Re: �Catastrophic� Interpretations

Sections of the media (as expected) and a number of health professionals (unexpected) have read too much into the results of West and Sohal and drawn a number of hasty and unguarded conclusions. These should be challenged before they pass into folk-law.

(1) Not planning a quit attempt is a better strategy than planning it. Blanket statements on efficacy are clearly premature given the nature of this study. Such a conclusion would only be appropriate following a randomized trial, with the two methods compared on a like-for-like basis. Indeed, several such trials would normally be necessary before such a finding, if true, could be considered part of the evidence base. This was an observational study with two self-selected groups and those using the two strategies may have been very different with respect to characteristics that might naturally have predisposed them to succeeding or failing, regardless of the strategy they used. For instance, it is possible that those who felt they could quit at that point in time without planning in advance may have been less dependent on tobacco and more highly motivated, while those who chose to plan ahead, while seeing the need to quit, may have had poor motivation and confidence. Their planning to quit at a time in the future may simply have been procrastination. There are other possible scenarios that could be envisaged. Hence, we cannot even be sure that each smoker used the best strategy to suit them at that particular time. We do not know how successful those who chose not to plan would have been if instead they had been persuaded to, or how successful the �planners� would have been if instead they had been persuaded to quit immediately. These are questions which only carefully controlled trials can answers.

(2) A second incorrect interpretation is that an attempt to quit without planning gives a 65% chance of success for at least 6 months. This is clearly not the case since the data do not provide an estimate for the likely success of an individual quit attempt, but rather an accumulation of cessation over time. The fact that only about 50% reported having made an attempt to stop in the last 5 years may suggest that failed attempts have in retrospect been dismissed as not serious and hence not been reported in the study. If so this will have reduced the number of continuing smokers included in the cumulative cessation rate.

(3) NHS services need to change their protocols in response to the results. With (1) in mind no firm conclusions or recommendations can be made. Even if it had been a controlled trial, the study did not address issues relating to the structured treatment protocols used in the NHS. Although the study may have included a few smokers who made their last quit attempt with NHS help, by and large these will have been self-help attempts. Making ones own plans and trying to stick to them is possibly less effective that if the planning is done for you and there is someone else to support you and keep you on track. When left alone with a difficult task we all tend to be poor planners.

Perhaps the soundest conclusion from West�s results is that they provide a stimulus fro further work in the area and possibly encourage a controlled trial. This in itself is not an inconsiderable achievement. For smokers making self-help quit attempts the simple advice should remain unchanged: choose a day that you know will not be particularly stressful. It is quite likely that even those in this study who didn�t plan their quit attempt nevertheless had this in the back of their mind at the time.

Competing interests: JAS has acted as an occasional adviser on the development of smoking cessation technologies and programmes to commercial organisations, the Department of Health, the Health Development Agency, NICE and the MRC.

Drawing unwarranted conclusions 1 February 2006
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Robert West,
Professor of health Psychology
University College London, WC1E 6BT

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Re: Drawing unwarranted conclusions

When reporting the findings that a substantial proportion of quit attempts are unplanned and that unplanned ones appear to be more likely to be successful than planned ones I was sensitive to the possibility that commentators would interpret the findings incorrectly and that, alas is what has happened in both the media and in some of the Rapid Responses received thus far. First of all, parts of the media have susbtituted 'stopping on a whim' or 'cold turkey' for unplanned quit attempts. Neither of these terms is appropriate. There is no reason to suppose that the quit attempts were made whimsically and it is quite possible that having started the quit attempt the smokers went on to use some form of assistance such as nicotine replacement therapy. Secondly there is no basis whatsoever for the inference that people should not plan their attempts in advance. This study was about what people do, not about what they should do, and we were careful to point out that our findings may well reflect the state of mind of smokers at the point where they make the quit attempt rather than anything else - indeed that was the basis for the 'catastrophe theory' hypothesis. Systematic reviews and meta-analyses of randomised controlled trials indicate that psychological support and medications such as nicotine replacement therapies increase smokers' chances of stopping successfully and our data cannot alter that conclusion.

John Stapleton's Rapid Response is an important correction to these misconceptions and I fully ensorse his call for further research. In the first instance we need data from cohorts of smokers exploring the natural history of cessation. I hope that this study will be a stimulus to such research.

Competing interests: I was author of the article and also undertake research and consultancy for companies that develop and manufacture smoking cessation products. In addition I contribute to guidance for the stop smoking services.

Carpe Diem 1 February 2006
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Stevie M Gamble,
retired HMIT

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Re: Carpe Diem

West and Sohal claim in their paper, ' "Catastrophic� pathways to smoking cessation: findings from national survey' (1.) that:

'use of behavioural support and nicotine replacement therapy are known to improve the chances of success even though they generally require planning ahead',

citing the NICE guidance issued in 2002 (2.) as authority for this statement.

The evidence cited in the NICE guidance says no such thing; it is based entirely on clinical trials pitting placebo against nicotine supplementation. There is no evidence that the people in those trials were planning ahead; indeed, quite the reverse. The people running the trials were doing the planning, the patients were the passive recipients of that planning.

One could, I suppose, argue that the patients' willingness to take part in the research implied planning ahead on their part, but one would need evidence to support it, and there is no such evidence. Even if there were, one must assume that it applies to all the participants, leaving one with the conclusion that if you are planning ahead to give up smoking then using nicotine substitution may be helpful. It says nothing at all about the relative merits of 'I did not plan the quit attempt in advance; I just did it -to use the wording in West and Sohals' survey- and planning ahead.

Improbable as it may seem, the media's interpretation of the evidence in this paper is rather more accurate than the authors'�

Stevie Gamble

1. �Catastrophic� pathways to smoking cessation: findings from national survey BMJ, doi:10.1136/bmj.38723.573866.AE (published 27 January 2006)

2. National Institute for Clinical Excellence. Nicotine replacement therapy (NRT) and bupropion for smoking cessation. London: NICE, 2002. (Technology appraisal guidance No 38.) http://www.nice.org.uk/page.aspx?o=30590

Competing interests: None declared

Misinterpretation of West & Sohal 3 February 2006
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Saul Shiffman,
Professor of Psychology, Psychiatry, and Pharmaceutical Sciences
University of Pittsburgh, Pittsburgh, PA, USA 15213,
Jack E. Jenningfield, Ph.D. Sidney H. Schnoll, M.D., Ph.D.

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Re: Misinterpretation of West & Sohal

We read with interest the paper by West & Sohal documenting that some smokers quit without explicit preparation and that these smokers may be more successful than those who planned their quit attempt.

Unfortunately, these findings have been misinterpreted in widespread media coverage of the paper as implying that planning impedes quitting and ought to be discouraged. This is not true. An association between unplanned quitting and success does not imply that planning has adverse consequences. Smokers who quit suddenly are likely to have been affected by a powerful motivating event that creates a strong incentive for abstinence, a phenomenon that has long been recognized in �spontaneous recovery� from drug addiction (1). Conversely, some smokers� self-reports of long planning periods may be markers of procrastination and ambivalence, which would lower smokers� chances of success. It�s also plausible that smokers initially try top quit spontaneously, and only engage in planning after they have already experienced several failures, so those who plan may be harder cases. Importantly, the use of behavioral and pharmacological treatments, which require at least some planning, have been shown in dozens of randomized trials to improve success rates. The findings of West & Sohal suggest that such treatments ought to be made easily accessible on short notice, so that they are available to smokers as soon as they decide to quit, and so that treatment can be offered to smokers have already quit.

Saul Shiffman, Ph.D.
University of Pittsburgh & Pinney Associates

Jack E. Henningfield, Ph.D.
Johns Hopkins University & Pinney Associates

Sidney H. Schnoll, M.D., Ph.D.
Virginia Commonwealth University School of Medicine, Columbia University
College of Physicians and Surgeons, and Pinney Associates

(1) U.S. Department of Health and Human Services. (1988). The health consequences of smoking: nicotine addiction, a report of the Surgeon General. Washington, DC: U.S. Government Printing Office.

Competing interests: The authors consult to GlaxoSmithKline Consumer Healthcare regarding smoking cessation products. SS and JEH also have an interest in a smoking cessation product under development.

Setting Quit Dates 7 February 2006
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Joel Spitzer,
Health Educator
Conduct Stop Smoking Clinics for the Evanston and the Skokie Illinois Health Departments 60201,60076

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Re: Setting Quit Dates

Below is a short commentary��I wrote in February of 2004 at�an online quit smoking forum I was co-managing.��I wrote it for both members of the online support group and visitors reading at the site. I was trying to pass along an observation that I realized decades ago when I first started talking to people who were quitting smoking. I was trying to encourage them to survey people who had stopped and were now long-term ex-smokers. I have worked with and talked extensively with over�forty five hundred smokers since conducting my first clinics in the mid 1970's. I have also encouraged all of those people to talk to all of the ex-smokers they ever knew. In all that time I have never heard any of them come back saying that the results they came up with varied differently with what I had observed.

Here again is the piece I wrote in�2004 for�an online quitting support group. �I feel that this survey and the ensuing discussion ties very well in with this piece:

Setting quit dates

Conventional wisdom in smoking cessation circles says that people should make plans and preparations for some unspecified future time to quit. Most people think that when others quit smoking that they must have put a lot of time into preparations and planning, setting quit dates and following stringent protocols until the magic day arrives.

When it comes down to it, this kind of action plan is rarely seen in real world quitters. I emphasize the term real world quitters as opposed to people quitting in the virtual world of the Internet. People who seek out and participate in Internet sites do at times spend an inordinate amount of time reading and planning about their quits before taking the plunge. Even at our site we see people say they were reading here for weeks or months before finally quitting and joining up. Although I suspect there are a fair number of people who had already decided to quit right away and searched us out after their quit had begun, and some people who may not have actually decided to quit but who when finding WhyQuit.com and seeing cigarettes for what they are decided then and there to start their quits.

Getting back to real world experience though, the best people to talk to when it comes to quitting smoking are�those who have successfully quit and have successfully stayed off for a significant period of time. These are people who have proven that their technique in quitting was viable considering they have quit and they are still smoke free. Talk to everyone you know who is off all nicotine for a year or longer and find out how they initially quit smoking. You will be amazed at the consistency of the answer you get if you perform that little survey.

People are going to pretty much fall into one of three categories of stories. They are:

People who awoke�one day and were suddenly sick and tired of smoking. They tossed them that day and never looked back.

People who get sick. Not smoking sick, meaning some kind of catastrophic smoking induced illness. Just people who get a cold or a flu and feel miserable. They�feel too sick to smoke, they may feel too sick to eat. They are down with the infection for two or three days, start to get better and then realize that they have a few days down without smoking and decide to try to keep it going. Again, they never look back and stuck with their new commitment.

People who leave a doctors office who have been�given an ultimatum. Quit smoking or drop dead--it's your choice. These are people for whom some sort of problem has been identified by their doctors, who lay�out in no uncertain terms that the person's life is at risk now if they do not quit smoking.

All of these stories share one thing in common--the technique that people use to quit. They simply quit smoking one day. The reasons they quit varied but the technique they used was basically the same. If you examine each of the three scenarios you will also see that none of them lend themselves to long-term planning--they are spur of the moment decisions elicited by some external circumstance.

I really do encourage all people to do this survey, talking to long- term ex-smokers in their real world, people who they knew when they were smokers, who they knew when they quit and who they still know as ex- smokers. The more people do this the more obvious it will become how people quit smoking and how people stay off of smoking. Again, people quit smoking by simply quitting smoking and people stay off of smoking by simply knowing that to stay smoke free that they must never take another puff!


I really do encourage all�medical professionals to�conduct this survey, talking to your long term ex-smoking patients,�colleagues, family��members�and friends. People who�you knew when they were smokers, who�you knew when they were quitting and who�you still know as being successful long-term ex-smokers. The more people�that�medical professionals talk to, the more obvious it will become�to them�how people quit smoking and how people stay off of smoking. Again, people quit smoking by simply quitting smoking.

I don't believe that there is a single professional smoking cessation "plan your quit" advocate who will suggest�other medical professionals�should take a similar survey. For if they did their�study results would�almost certainly be called into question when the�health care professional�starts seeing the results of�his or her real life survey.�The experts will end up having to spend quite a bit of time trying to explain away the discrepancy, using�rationalizations like the people who planned their quit�"didn't do it right" or didn't "plan" long enough or were�"just more addicted smokers."�

I�see that one of the authors of this study and a few other commentators who clearly have ties to pharmaceutical interests have tried to link this survey results to the need to recommend pharmaceutical interventions. As long�as�I am asking all health care professionals to survey their own patients and others who they associate with as to the kind of planning they had done to quit, I suggest that all health care professionals go the extra step and find out how�many of the successful long-term ex-users* of nicotine actually used�pharmaceutical�products to quit. They will likely find that most of the long-term successful ex- users* that they survey will not have used any of these products in the quit that actually succeeded.�Tying pharmaceutical intervention recommendations to the results of surveys showing that spontaneously quitters as being more successful seems totally unwarranted and I suspect that all health care professionals who conduct their own surveys will also come to this very obvious conclusion.

*Long-term ex-user being defined as an individual who has not used any nicotine from any source for at least a year or longer.

Joel Spitzer has over 30 years of experience in the development and implementation of smoking cessation programs for adults and smoking prevention programs for children in the Chicagoland area. While with the American Cancer Society (Chicago Unit, Illinois Division)and the Rush North Shore Medical Center and now for the Evanston and Skokie Illinois Health Departments he has conducted over 350 stop smoking clinics with over 4,500 participants. He has also presented over 570 educational seminars to over 90,000 children and adults on smoking prevention.

Competing interests: Educational Director of WhyQuit.com, the Internet's leading abrupt nicotine cessation resource.

Market Segmentation 7 February 2006
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Peter D Singleton,
IT Consultant
Cambridge CB3 9HH

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Re: Market Segmentation

I am constantly surprised by the medical community treating patients as though they were a homogeneous bunch - much as that is a nice assumption for statistical purposes and RCTs.

In industry, marketing departments presume that there are different segments of a population with varied objectives and values, who will react differently to marketing messages and may require radically different products or brands to meet their needs or perceived needs. Smokers also vary � many take it up through peer pressure, perhaps supported by advertising and brand image; some are simply used to smoking as a family, so have no reason not to smoke, taking it as a social norm (as was the case in the middle of the last century). Again people continue to smoke for a variety of reasons: nervousness, addiction, simple habit, social pressure, etc.

More interesting might be why people give up: some give up when they realise just how much they are spending; some when they realise just what the real health implications are; some succeed in giving up after a long struggle against the habit; some find social opprobrium a reason to stop; some just never want to give up at all.

What may help more is to know what helped people to stay off smoking once they decide to give up. A planned approach may help some realise that they can have the will to give up by practising self-discipline and learning coping strategies � for many it will be like swimming in the North Sea, either you take the plunge or you don�t swim � there are very few that I know who can do it slowly a stage at a time � usually that leaves you too much time to change your mind!

Competing interests: None declared

the ethics of banning smoking 7 February 2006
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A Larbi,
undergraduate medical physiology

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Re: the ethics of banning smoking

I have read various peices over the last few months on the proposed smoking ban, and i cant see what all the hoo haa is about!

Smokers dont really care if smoking is ostracised, they are going to smoke anyway, at least they should see that the government is trying to be ethical in its approach to cutting the amount of passive smokers there are.

It worked in Ireland why not in the UK? I think there is too much political correctness and not enough commonsense.

Competing interests: None declared

Re: Setting Quit Dates 8 February 2006
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Joan McClusky,
Med cal writer
New York, NY 10003

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Re: Re: Setting Quit Dates

This writing points up the "through the looking glass" approaches now being used in so much of medicine--on the one hand, treatment needs to be individualized, cultural differences must be respected, effective treatment is the result of a partnership between healthcare professional and patients, etc, etc. On the other hand, healthcare providers are on some level galled if the paradigms they envision for "changing health related behaviors" (or some other such awful phrase)don't actually work.

Competing interests: None declared

Flawed reasoning 10 February 2006
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Kevin R Lewis,
Associate Specialist in Public Health
Shropshire County Primary Care Trust, William Farr House, Mytton Oak Road, Shrewsbury SY3 8XL

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Re: Flawed reasoning

There seems to be a misapprehension creeping into some responses here, that because something commonly happens in a particular way 'in the real world' then this should be considered the best way. This is flawed reasoning.

While it is true that most smokers who quit do so without any specific behavioural support or pharmacological treatement, this does not preclude the possibility that they would have quit in much greater numbers had they received such support and treatment. Indeed, there is a wealth of evidence from published studies to show that supported quit attempts are much more successful than unsupported ones.

The fact that most quitters have had to manage it alone is cause for concern not celebration.

Competing interests: Founder of the NHS stop-smoking service �Help 2 Quit� which treats 6,000 smokers per year. Have occasionally provided consultancy, and undertaken research within the NHS, for companies that develop smoking cessation treatments.

In Search Of Catastrophes 14 February 2006
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James O Prochaska,
Director and Professor
Cancer Prevention Research Center, Univerisity of Rhode Island, 2 Chafee Road, Kingston, RI 02881

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Re: In Search Of Catastrophes

West and Sahol�s (2006) recent research addresses a challenging question. Does planning a quit attempt increase the chances that the quit attempt will last at least 6 months? The results of their retrospective research with a sample of British smokers leads them to conclude that planning quit attempts decreases the chances.

The authors suggest that their results are especially challenging for the stages of change model. The fact is, if taken at face value, their results would be particularly challenging for almost all evidence-based treatments for smoking cessation. From their measures it would appear that one of the best indicators of planning would be setting a quit date. Helping participants set a quit date is an important part of most cessation approaches, especially those designed for motivated smokers who are prepared to quit in the next month. Given the results of their research, it would seem that the authors would have to disclose to smokers that setting a quit date would be likely to more than double the chances that their quit attempt would fail to last at least six months.

It might surprise the authors to learn that in our TTM based population cessation approach we do not try to get most participants to set a quit date during treatment because they are not ready.

The authors recognize the conundrum their results seem to create when they write: �These findings do not necessarily imply that planning quit attempts is counterproductive, and use of behavioral support and nicotine replacement therapy are known to improve the chances of success even though they generally require planning ahead?� But the authors provide no evidence or argument against the implications that planning quit attempts is counterproductive. The researchers and the readers are caught between hundreds of prospective RCT�s that strongly suggest that planning quit attempts is productive and this single retrospective study that suggests otherwise.

Let�s take a closer look at this study to see why their results shouldn�t be taken too seriously. First of all it makes no sense to include ex-smokers in Table 2, since by definition 100% of planned and unplanned attempts of ex-smokers would have to be successful and to have lasted at least six months. Second, amongst current smokers 100% of the planned and unplanned quit attempts failed, teaching us nothing about the long-term efficacy of each approach. Third, the data presented indicate that the percentage of people remembering planned quit attempts ranges from about half in Table 1 that includes quit attempts over 5 years to about two-thirds from those having quit in 6 to 12 months in Table 2.

Finally, based on �catastrophe theory� the authors recommend that with smokers who are on the cusp of change in their orientation to smoking, treatment needs to be made available immediately. Remember that planning for later the same day, the next day or in a few days would hurt their quit attempt. Are we going to have smokers go immediately to the emergency room to seek cessation treatment? That would be a catastrophe!

West keeps insisting that he has a solution that is superior to the stage of change model. This article suggests that he needs to keep searching.

Competing interests: None declared

More misunderstanding 15 February 2006
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Robert West,
Professor of Health Psychology
University College London WC1E 6BT

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Re: More misunderstanding

Prochaska's commentary assumes that the article makes a claim which it explicitly does not do. The findings cannot possibly be used to support the argument to plan a quit attempt is a bad idea and we explicitly say so in the article. The results can be interpreted in a number of ways but the hypothesis that we put forward was that sudden quits reflect a greater unconflicted commitment on the part of many of those making them than ones that are planned ahead. What is challenging to the stages of change approach is that sudden quits are so common and that so many of them succeed - the observation that they are statistically more likely to be successful than planned ones is a pointer to future research regarding the true processes by which this kind of change occurs.

As regards the interpretatation of the data by Prochaska, this is confused. Of course it makes sense to include ex-smokers in calculating the percentage of quit attempts that succeeded - the point is that the denominator also includes people who did not succeed and the ratio of the two is what is of interest. Secondly, the analysis involving smokers who relapsed was included to demonstrate a particular point as stated in the paper and of course lasting longer than 6 months, even if there is subsequent relapse, reflects greater success than lasting less than 6 months. Finally, there is no doubt that quit attempts are forgotten and we acknowledge this which is why we showed that the difference between planned and unplanned quit attempts was robust to examination over different time periods.

Competing interests: As declared in the original artical

Health insurance coverage for smoking cessation treatment 24 February 2006
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Hiroshi Kawane,
The Japanese Red Cross Hiroshima College of Nursing

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Re: Health insurance coverage for smoking cessation treatment

I read with great interest the article on smoking cessation by West and Sohal [1]. In Japan, health insurance coverage is decided to extend to the treatment of nicotine addiction from April 2006. Tobacco smoking has now come to be recognized as a disease that requires treatment at least in part. The Ministry of Health, Labor and Welfare plans to cover doctors' smoking cessation counselling fees with public health insurance schemes, expecting to stem the nation's ballooning medical costs. Patients who want to quit immediately must agree to being enrolled in a 12-week smoking treatment program. The result of their study that unplanned quit attempts were more likely than planned ones to be successful is encouraging.

Reference [1]West R, Sohal T. "Catastrophic" pathways to smoking cessation: findings from national survey. BMJ 2006;332:458-460.

Competing interests: None declared

The theory is pragmatic - now we need a practical application 25 February 2006
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Andrew J Ashworth,
GP Principal
Davidson's Mains Medical Centre, 5 Quality Street, EDINBURGH, EH4 5BP

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Re: The theory is pragmatic - now we need a practical application

Work that supports those of us at the �front line� of behaviour change is always welcome. Simplifying motivational interventions to 3 T�s is helpful to busy practitioners with a lot to do in a short time. The theoretical model offered here has face validity but does not extend the bidirectional nature (described as �tension�) of motivation between change to the new behaviour or to relapse. Simple extension of this bidirectional principle to the second 2Ts permits us to consider reducing Triggers to relapse, for example in legislation to ban smoking in public places and advising against immediate availability of relapse �Treatment� by, for example disposing of cigarettes within the home of the quitter. Furthermore (presumably because of our profession�s unscientific obsession with cessation in nicotine addiction despite its advocacy for harm reduction and substitution in other forms of addiction) only two outcomes, cessation and relapse from cessation are measured and included in this theoretical model. A host of comentators has already made negative rapid responses based on their own points of view (making one's living from anything to do with smoking cessation is as much a competing interest as owning shares in a tobacco company!) derived from subjects who probably self selected anyway. This work has already been misrepresented in the media as implying that behavioural change interventions are ineffective.

As a GP I find the message both pragmatic and welcome. Despite those in the cessation "industry" with vested interests in making things difficult, we now need simple tools for assessing motivational tension, be supported by public policy that gives positive health & negative relapse triggers and have better availability and funding of treatment, particularly the use of long term nicotine substitution (patches) as harm reduction intervention for secondary prevention in COPD and Cardiovascular disease.

Competing interests: None declared

There is no need to re-invent this particular wheel. 27 February 2006
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Peter O'Loughlin,
Robert West, Taj Sohal

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Re: There is no need to re-invent this particular wheel.

Professor West's suggestions that people quit smoking spontenously without going through the 'stages of change' appears to overlook the unconscious processes of consideration, that they are likely to have undergone.

Given the frequent, extensive, highly emotive advertising campaigns preaching the evils of smoking, some of which border on emotional blackmail, it is to say the least, highly unlikely that there are any smokers who have not been affected to a greater or lesser degree. Indeed research published in the American Journal of Preventive Medicine,(AJPM) (1)compared the impact of televised advertising campaigns promoting smoking cessation, with seven conventional types of cessation help, including NRT.

The sudy showed that the televised ads were by far and away the most influential in people deciding to quit, thereby confirming what the Chinese discovered two thousand plus years ago, that if you tell someone something often enough, they come to believe it.

Since it is almost impossible for us to act in any way but in accordance with our beliefs, it follows that those who quit went through the stages of 'precontemplation', 'contemplation', 'preparation' and action', either immediately following the first advertisement, or more likely the progress through the stages, came about with the frequency of the campaigns; whether or not this was a conscious or unconscious process is irrelevant. It certainly was not spontenous, or an 'impulse buy'.

No one relinquishes a habit or behaviour from which they perceive they are receiving some benefits, without considering ('contemplating') compensating factors. Indeed if that were the case we would not have the horrendous problems of drug and alcohol addiction in our society.

I do not think it is the cycle of change that is flawed, nor does that wheel need re-inventing.

Peter O'Loughlin, Addictions Counsellor.

1 Biener,Lois; Reimer, Rebecca L; Wakefield, Melanie; Szczpka; Rigotti, Nancy and Connelly, Gregory: AMJP: Vol. 30. Issue 3. (March 2006)

Competing interests: None declared

Who is afraid of doing so? 28 February 2006
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Ben P Ponsioen,
Brielle Slagveld 42 3231AP The Netherlands

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Re: Who is afraid of doing so?

The cross sectional household survey of West and Sohal hypothesizes that[1]:

1) smokers need to go through the stages of Prochaska and diClemente before stopping
2) most of the quit-attempts are unplanned
3) unplanned quit-attempts are more successful than planned ones

The results of West and Sohal confirm the hypotheses 2 and 3. However the suggestion of the authors that smokers need to pass through the stages of pre-contemplation, contemplation, preparation and action does not hold true. These stages, as described by Prochaska and diClemente, are since long valid tools that help us to decide which approach will be effective.

When the patient is a (pre)contemplator the doctor will rather talk about nicotine replacement, bupropion or nortryptiline than prescribe those drugs. Prescription may be justified during the stage of preparation or action. In Dutch general practice 10% of the COPD patients who stop smoking receive prescriptions[2].

Interestingly, West en Sohal support the relevance of recognizing the patients� motivational stage. Moreover, they clearly demonstrate that doctors might underestimate the effectiveness of their patients with regard to quit smoking. Patients with planned quit attempts select themselves for visits compared while catastrophic stop-smokers do less.

As to West and Solal, catastrophic pathway stopping is driven by high levels of �motivational tension� and subsequent effects of small �triggers�. It seems likely that �catastrophic� smoking cessation is associated with influx of endorphins and other neurotransmitters in the brain. This implies that a doctor when guiding a stop smoking attempt sometimes touches the patients� emotions and must deals with the patients� mood. Who is afraid of doing so?


1) West R Sohal T. "Catastrophic" pathways to smoking cessation: findings from national survey. Br Med J 2006;332:458-60

2) Hilberink SR, Jacobs JE, Bottema BJ, de Vries H, Grol RP. Smoking cessation in patients with COPD in daily general practice (SMOCC): six months' results. Prev Med 2005;41:822-7

Competing interests: None declared

Recollection Bias? 3 March 2006
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Corinne A. Keet,
Pediatric Resident
Johns Hopkins, 21202

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Re: Recollection Bias?

Dear Editors,

There is another potential bias in "'Catastrophic' pathways to smoking cessation" that could significantly affect the results of this study. If a subject made an unplanned attempt at quitting smoking that lasted for a short time, he may be unlikely to remember this attempt, and even less likely to identify it as a "serious attempt". In contrast, if he planned to quit for weeks or months he might be much more likely to remember, even if he never stopped smoking. This recollection bias can only be remedied by prospective studies that ask if a subject is currently engaged in a "serious attempt at quitting smoking".

Competing interests: None declared

Possible (non-catastrophic) errors in Table 2 9 March 2006
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Salaheddin M. Mahmud,
Community Medicine Resident
University of Manitoba, Winnipeg, Canada R3E 0W3

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Re: Possible (non-catastrophic) errors in Table 2

As professor Prochaska remarked in his Rapid Response the inclusion of ex-smokers in Table 2 does not make sense because by definition all ex-smokers succeeded in their last attempt, planned or unplanned, in abstaining for more than 6 months. In other words, by definition every ex-smoker has the outcome under consideration (abstinence > 6 months). Professor West did not find this argument convincing. To illustrate the point, I computed a 2-by-2 table for the ex-smokers only using data given in Table 2. The first section in Table 2 gives the total number of current smokers and ex-smokers who made a quit attempt between 6 months and 5 years previously. The third section gives the same figures for current smokers only. So by subtracting the numbers in the third section from the corresponding numbers in the first section, we obtain the required 2-by-2 table for the ex-smokers only (see tables below). Out of 220 ex-smokers, only 5 (2%) fill in the category �lasted < 6 months� with only one individual in the �unplanned attempt� category. (This is probably due to a programming error as this number should have been zero.) In any case, and as expected, the data for ex-smokers are not of much use in calculating an odds ratio (OR) for the association with type of attempt. The OR would have been incalculable if it was not to the five �misclassified� cases.

Section 1 of Table 2: No. of current and ex-smokers by type of attempt and success status
















OR= 2.6

Section 3 of Table 2: No. of current smokers only by type of attempt and success status
















OR= 2.4

Back-calculated numbers (section 1 minus section 3) for ex-smokers only




% lasted 6mo+
















OR= 5.2

Salaheddin Mahmud, MD, MSc

Department of Community Health Sciences, University of Manitoba

S111 � 770 Bannnatyne Avenue

Winnipeg, Manitoba R3E 0W3


Competing interests: None declared

Re: Possible (non-catastrophic) errors in Table 2 12 March 2006
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Robert West,
Professor of Health Psychology

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Re: Re: Possible (non-catastrophic) errors in Table 2

I am sorry to say that the analysis by this author is nonsense. It should be apparent from the definition of the denominator (participants who made their most recent quit attempt between 6 months and 5 years ago) that there cannot be ANY participants who are ex-smokers who lasted less than 6 months! The fact that there were 5 ex-smokers who reported their most recent quit attempt as being at least 6 months ago and it lasting less than 6 months is just a reflection of the fact that this in the this small number of cases they made mutually inconsistent responses to different items on the questionnaire.

I can only repeat the point I made to Prochaska in the hope that this author and Prochaska will be able to understand it. The denominator for the calculation has got nothing to do with whether participants are smokers or ex-smokers - it is simply the number of people who made their most recent quit attempt at least 6 months ago. Whether these are planned or unplanned is similarly defined completely independently of whether the participants are smokers or ex-smokers. So the only point where the fact that they are ex-smokers comes in is in the OUTCOME. Therefore there can be no tautology here.

There are many other potential sources of bias in this kind of retrospective data and so it will be important to check these findings with prospective studies.

Competing interests: As stated in the original article