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Resurrecting Abrupt Nicotine Cessation

Posted by JohnRPolito on 15 Jul 2018 at 11:10 GMT

What’s newsworthy from the July 8, 2018 PLoS ONE paper “Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015–2016”? [1] It could have been that when taking smoking cessation Table 7 categories and numerators at face value in this longitudinal cohort study of 374 smokers, while considering only complete smoking cessation, that harm elimination via cold turkey was 4.6 times more productive (56 vs. 12 quitters) and 5.8 times more effective (43.4% vs. 8.3%) than harm reduction via electronic nicotine delivery systems use (ENDS). [1]

It could have been that cold turkey quitting clobbered nicotine replacement therapy (NRT) in being 11 times more productive (56 vs. 5 successful quitters) and 3.3 times more effective (43.4% vs. 13.1%).[1] Unfortunately, one Table 7 data classification, cold turkey, does not mean what it says.

While the authors are to be commended for undertaking the herculean task of assessing the population impact of “real world” use of electronic nicotine delivery systems (ENDS), investigating harm reduction is not license to definitionally dismember the commercial cigarette’s 153-year reigning king of harm elimination (in terms of cessation productivity), cold turkey.

In 1973, Webster’s defined “cold turkey” as “abrupt complete cessation of the use of an addictive drug either voluntarily or under medical supervision.”[2] Today, Merriam-Webster’s online definition is largely unchanged: “abrupt complete cessation of the use of an addictive drug.”[3]

The authors define “cold turkey” in Table S1 to mean that the smoker “gave up cigarettes all at once.”[4]

Clearly, cigarettes can be instantly, fully and permanently traded for nicotine rich Copenhagen, 4mg Nicorette gum, or hundreds of flavors of ENDS e-juice. Thus, it is not cold turkey or abrupt nicotine cessation. It is abrupt smoking cessation.

Definitions have consequences. For example, it has taken three decades and gradual yet increasing awareness of population-level floundering of OTC NRT [1,5-10] for cessation group-think to begin awakening to the irony of having declared nicotine to be “medicine” and its use “therapy.”

A follow-up survey question for those responding “yes” to having given up “cigarettes all at once” would have identified “real” real-world cold turkey quitters: “when you gave up cigarettes all at once, did you also give up nicotine all at once, without use of Chantix (varenicline)?”

Why exclude varenicline use from cold turkey but not bupropion (Zyban)? Because, a partial agonist, varenicline mimics nicotine by increasing extracellular dopamine concentrations [11] while bupropion does not.[12]

In that this study’s survey independently assessed pharmacology, NRT, cigar, smokeless tobacco, ENDS use, and gradual nicotine weaning (see Table 7), why add a small yet unknown percentage of the first five forms of delivery to cold turkey?

Research is long overdue into the key or keys to successful abrupt nicotine cessation. Clearly the quitter’s natural cessation instinct, instead of discouraging cold turkey, as is done at SmokeFree.gov,[13-15] imagine science, health, government and higher learning playing major roles in transforming cold into smart turkey.

One closing request. A former three-pack-a-day smoker, I submit that dependency’s greatest harm isn’t some smoking related disease decades down the road or how we eventually die, but how each and every day gets lived. Contrary to a host of protective use rationalizations, living as a slave to a never-ending need-feed cycle chops-up life into the distance between feedings. I encourage all engaged in cessation to elevate the priority of harm elimination above harm reduction.

References:

1. Weaver SR, Huang J, Pechacek TF, Heath JW, Ashley DL, Eriksen MP (2018) Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015–2016.PLoS ONE 13(7):e0198047. https://doi.org/10.1371/ journal.pone.0198047
2. G. & C. Merriam Co., Webster’s New Collegiate Dictionary 1973, cold turkey, page 219.
3. www.Merriam-Webster.com, cold turkey, https://www.merriam-webst...
4. Weaver SR, et al, (2018) Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, S1 Table, Detailed description of measures and variable construction, Page 18 of 19. https://doi.org/10.1371/j...
5. Leas EC, Pierce JP, Benmarhnia T, White MM, Noble ML, Trinidad DR, Strong DR, Effectiveness of Pharmaceutical Smoking Cessation Aids in a Nationally Representative Cohort of American Smokers. J Natl Cancer Inst. 2018 Jun 1;110(6):581-587. doi: 10.1093/jnci/djx240. PMID: 29281040
6. Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world". Mayo Clin Proc. 2014 Oct;89(10):1360-7. PMID: 25282429
7. Pierce JP, Cummins SE, White MM, Humphrey A, Messer K. Quitlines and nicotine replacement for smoking cessation: do we need to change policy? Annu Rev Public Health. 2012 Apr;33:341-56. PMID: 25282429
8. Doran CM, Valenti L, Robinson M, Britt H, Mattick RP, Smoking status of Australian general practice patients and their attempts to quit. Addict Behav. 2006 May;31(5):758-66. PMID: 16137834
9. Pierce JP, Gilpin EA. Impact of over-the-counter sales on effectiveness of pharmaceutical aids for smoking cessation. JAMA. 2002 Sep 11;288(10):1260-4. PMID: 12215133
10. Alberg AJ1, Patnaik JL, May JW, Hoffman SC, Gitchell J, Comstock GW, Helzlsouer KJ. Nicotine replacement therapy use among a cohort of smokers. J Addict Dis. 2005;24(1):101-13. PMID: 15774414
11. Di Ciano, P., Guranda, M., Lagzdins, D., Tyndale, R. F., Gamaleddin, I., Selby, P, Le Foll, B. (2016). Varenicline-Induced Elevation of Dopamine in Smokers: A Preliminary [11C]-(+)-PHNO PET Study. Neuropsychopharmacology, 41(6), 1513 - 520. http://doi.org/10.1038/np... PMID: 4832011
12. Egerton, A., Shotbolt, J. P., Stokes, P. R. A., Hirani, E., Ahmad, R., Lappin, J. M., … Grasby, P. M. (2010). Acute effect of the anti-addiction drug bupropion on extracellular dopamine concentrations in the human striatum: An [11C]raclopride PET study. NeuroImage, 50(1), 260–266. http://doi.org/10.1016/j.... PMID: 19969097
13. SmokeFree.gov at https://smokefree.gov/too... The site’s quitting methods page does not list or mention cold turkey among its 16 options.
14. SmokeFree.gov at https://smokefree.gov/qui... “One of the best ways to deal with nicotine withdrawal is to try nicotine replacement therapy (NRT) … NRT can double your chances of quitting smoking for good.” Immediately following the topic smokers are told, “It is difficult to quit smoking on your own, but quitting ‘cold turkey’ is not your only choice.”
15. National Cancer Institute, Clearing the Air, NIH Publication No. 08-1647, Printed October 2008, as linked and shared at SmokeFree.gov https://smokefree.gov/sit... The following appears under the “Cold Turkey” heading on booklet page 10: “Cold turkey: For some smokers, “going cold turkey” seems like the easiest way to quit: Just stop smoking and tell yourself you’ll never light up again. This works for some smokers - usually those with the lowest level of nicotine dependence - but not many. Fewer than 5 percent of smokers can quit this way. Most people aren’t prepared when smoking habits and withdrawal symptoms trigger an intense urge to smoke. Research shows that most smokers have more success with one of the assisted quit methods discussed below.”

Competing interests declared: 1999 founder and pro bono director of WhyQuit.com, a cold turkey nicotine dependency recovery site and author of Freedom from Nicotine - The Journey Home, a cold turkey quitting book.