For some time, nicotine replacement therapy (nicotine patches and gums) has been the sine qua non of pharmacological treatment for addiction. NRT's pedigree is unassailable -- if smoking addiction is due entirely to maintaining cellular nicotine levels, then replacing nicotine through non-smoking means is the cure for smoking.
NRT fits neatly into a number of industries. First, of course, is the National Institute on Drug Abuse's and the American Board of Addiction Medicine's "addiction as brain disease" model, premised on the belief that we will discover pharmacological cures for chemically-based addictions. Then there are the drug companies that manufacture and heavily market chemical cures for smoking. This is an industry whose revenues have increased ten-fold in the last decade and to whom most of the leading researchers in the field are beholden for support.
Ironically, one other industry that favors NRT includes the most radical critics of current addiction practices -- drug policy reformers. Such reformers are among those who favor so-called harm-reduction techniques like NRT. Harm reduction indicates that addicts can improve their lives without quitting their addictions, which NRT does by creating an alternative nicotine addiction that doesn't involve inhaling tobacco smoke.
But research on nicotine replacement has always shown quite a few iffy spots -- like the spots smokers develop on their lungs. For, although clinical trials show NRT patients do better at quitting cigarettes, surveys of smokers who have quit or tried to quit typically do not find any advantage for those who rely on NRT. Here is one such study that found self-quitters succeeded twice as often as pharmacologically treated smokers.
Thus, a new study that prospectively (over time) followed 800 smokers trying to quit who either employed NRT or who quit without it has drawn intense interest. The results -- reflected in the title, "A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation" -- were that recipients of NRT did no better than those quitting unaided. Indeed, heavily dependent smokers who resorted to NRT actually had twice the likelihood of relapsing as those who did it on their own.
How is that possible, we might ask. The key to quitting an addiction is motivation, along with a belief in the possibility of succeeding. It may be that those who turn to NRT are convincing themselves that (a) they can quit without the necessary personal commitment, (b) they can't quit on their own, based on their own personal strength and resources. The key, of course, is when the ex-smokers come off of the drug, when many soon relapse. This holds in the current study for the smokers most likely to fall under the brain disease rubric -- those who are most addicted.
Supporters of traditional smoking cessation programs immediately undercut the study's results (all quotes are from Benedict Carey, in the New York Times report of the study):
Doctors who treat smokers said that the study findings were not unexpected, given the haphazard way many smokers used the products. “Patient compliance is a very big issue,” said Dr. Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic, who was not involved in the study. [In other words, the therapy works great, but people don't use it correctly.]
“Some studies have questioned these treatments, but the bulk of clinical trials have unequivocally endorsed them,” said Dr. Michael Fiore, director of the University of Wisconsin’s Center for Tobacco Research and Intervention and the chairman of the panel that wrote the [government] guidelines [which recommend NRT for smoking cessation]. Dr. Fiore, who has reported receiving payments from drug makers, said that “there are millions of smokers out there desperate to quit, and it would be a tragedy if they felt, because of one study, that this option is ineffective.”
Obviously, there are those who support the use of such treatment, and those who oppose it. Except that the researchers who conducted the study in fact were NRT practitioners who expected it to be helpful.
“We were hoping for a very different story,” said Dr. Gregory N. Connolly, director of Harvard’s Center for Global Tobacco Control and a co-author of the study. “I ran a treatment program for years, and we invested” millions in treatment services.
Research that examines people in natural settings regularly finds different results than clinical (treatment) trials. The former demonstrate that people have considerable power to remedy their mental and addictive disorders without formal help; the latter tend to show fewer positive outcomes overall in clinical settings, and the worst results for the untreated.
As one of the researchers put it:
“Our study essentially shows that what happens in the real world is very different” from what happens in clinical trials, said Hillel R. Alpert of Harvard, a co-author with Dr. Connolly and Lois Biener of the University of Massachusetts, Boston.
It seems that the addicts in the current study simply don't understand how addiction, the brain disease, works. For them -- well, really, for all addicts -- "motivation matters a lot; so does a person’s social environment, the amount of support from friends and family. . ." If only we could eradicate these fundamentals of human behavior, then perhaps the brain disease theory would work.
Until then, however, treating addictions with mechanical, pharmacological, and medical cures will do more harm than good.
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