Effectiveness of a text-messaging-based smoking cessation intervention (“Happy Quit”) for smoking cessation in China: A randomized controlled trial


Abstract

Background

China has the highest global prevalence of cigarette smokers, accounting for more than 40% of the total cigarette consumption in the world. Considering the shortage of smoking cessation services in China, and the acceptability, feasibility, and efficacy of mobile-phone-based text messaging interventions for quitting smoking in other countries, we conducted a mobile-phone-based smoking cessation study in China.

Methods and findings

We conducted a randomized controlled trial in China across 30 cities and provinces from August 17, 2016, to May 27, 2017. Adult smokers aged 18 years and older with the intention to quit smoking were recruited and randomized to a 12-week high-frequency messaging (HFM) or low-frequency messaging (LFM) intervention (“Happy Quit”) or to a control group in a 5:2:3 ratio. The control group received only text messages unrelated to quitting. The primary outcome was biochemically verified continuous smoking abstinence at 24 weeks. Secondary outcomes included (1) self-reported 7-day point prevalence of abstinence (i.e., not even a puff of smoke, for the last 7 days) at 1, 4, 8, 12, 16, 20, and 24 weeks; (2) self-reported continuous abstinence at 4, 12, and 24 weeks; and (3) self-reported average number of cigarettes smoked per day. A total of 1,369 participants received 12 weeks of intervention or control text messages with continued follow-up for 12 weeks. The baseline characteristics of participants among the HFM (n = 674), LFM (n = 284), and control (n = 411) groups were similar. The study sample included 1,295 (94.6%) men; participants had a mean age of 38.1 (SD 9.79) years and smoked an average of 20.1 (SD 9.19) cigarettes per day. We included the participants in an intention-to-treat analysis. Biochemically verified continuous smoking abstinence at 24 weeks occurred in 44/674 participants in the HFM group (6.5%), 17/284 participants in the LFM group (6.0%), and 8/411 participants (1.9%) in the control group; participants in both the HFM (odds ratio [OR] = 3.51, 95% CI 1.64–7.55, p < 0.001) and the LFM (OR = 3.21, 95% CI 1.36–7.54], p = 0.002) intervention groups were more likely to quit smoking than those in the control group. However, there was no difference in quit rate between the HFM and LFM interventions. We also found that the 7-day point quit rate from week 1 to week 24 ranged from approximately 10% to more than 26% with the intervention and from less than 4% to nearly 12% without the intervention. Those who continued as smokers in the HFM group smoked 1 to 3 fewer cigarettes per day than those in the LFM group over the 24 weeks of trial. Among study limitations, the participants were able to use other smoking cessation services (although very few participants reported using them), cotinine tests can only detect smoking status for a few days, and the proportion of quitters was small.

Conclusions

Our findings demonstrate that a mobile-phone-based text messaging intervention (Happy Quit), with either high- or low-frequency messaging, led to smoking cessation in the present study, albeit in a low proportion of smokers, and can therefore be considered for use in large-scale intervention efforts in China. Mobile-phone-based interventions could be paired with other smoking cessation services for treatment-seeking smokers in China.

Smoking Linked to Higher Levels of Psychosis Symptoms


Smoking does not relieve symptoms of psychosis; on the contrary, it may actually worsen positive and depressive symptoms, new research shows.

These findings, investigators say, disprove the hypothesis that the high prevalence of smoking in this patient population is due to “self-medication.”

Investigators compared adult patients with non-affective psychosis to unaffected siblings and healthy controls and found that at baseline, close to 70% were smokers, compared with roughly a third of siblings and a quarter of controls.

Smoking was associated with increased positive, negative, and depressive symptoms as well as lower quality of life (QOL) in patients as well as in siblings, as compared to non-smoking patients and siblings — although patients experienced more symptoms than siblings.

Participants were followed for a 6-year period. During this time, patients who started to smoke showed a significant increase in symptoms, especially positive symptoms. On the other hand, smoking cessation was not associated with changes in symptoms or QOL.

“With respect to smoking and long-term symptoms levels and quality of life, we did not find any empirical support for self-medication,” lead author Jentien Vermeulen, MD, a PhD candidate in psychiatry at Amsterdam UMC, University of Amsterdam, the Netherlands, told Medscape Medical News.

Rather, said Vermeulen, it appears patients with psychosis who smoke do not experience improved cognitive functioning, symptoms, or quality of life but “actually suffer more.”

The study was published online December 5 in Lancet Psychiatry.

Treatment Hindered

“The prevalence of smoking is extremely high in individuals with psychotic disorder,” Vermeulen said.

“Some clinicians and researchers postulate that this can be explained because of potential benefits from nicotine and/or tobacco for individuals with psychosis, also known as self-medication. This belief hinders implementation of treatment programs to help patients quit smoking,” she said.

Vermeulen and colleagues previously studied whether smoking improves cognition in people with psychosis and found no longer-term benefit, but instead an exacerbation of cognitive symptoms. The current study was designed “to investigate whether there were any long-term benefits regarding symptom levels or quality of life for smokers, compared to nonsmokers.”

The researchers drew on participants within the Genetic Risk and Outcome of Psychosis (GROUP) cohort, consisting of patients with nonaffective psychotic spectrum diagnosis, their parents, unaffected siblings, and controls.

Based on the assumptions of the self-medication hypothesis, the researchers expected that smoking in patients with a psychotic disorder would be negatively associated with symptoms and positively associated with QOL.

The final sample consisted of 1984 patients with a noneffective psychotic disorder (66% with schizophrenia), 1047 siblings, and 157 controls.

Of the patients, 67% smoked an average of 17.5 (standard deviation [SD], 8.8) cigarettes per day, which was higher than the percentage smoked among siblings and controls (38% and 25%, respectively).

Mixed-effects analyses found that in patients, smoking was associated with more frequent self-rated positive, negative, and depressive symptoms (estimates 0.140 [standard error (SE), 0.024]; 0.145 [SE, 0.027]; and 0.120 [SE, 0.028], all Ps < .0001), compared with not smoking.

Smoking was also associated with lower quality of life (–0.59 [SE, 0.11], P < .0001 in patients; –0.31 [SE, 0.09], P = .0002 in siblings), compared with not smoking.

Lower Quality of Life

In siblings, significant associations were found between smoking and more frequent subclinical symptoms, while in controls, there was a significant association between smoking and more frequent subclinical positive and depressive symptoms.

Smoking and a higher number of cigarettes per day were associated with a higher frequency of self-rated symptoms (except for depressive symptoms) and a lower QOL across all three groups, when adjusting for age and sex, the authors report.

These “significant results” regarding positive (but not negative) psychosis symptoms and emotional distress were confirmed with clinician-rated PANSS data in patients, but not for negative symptoms.

The findings were not significantly affected when the researchers conducted analyses that accounted for covariates, including years of education and cannabis use in all groups and antipsychotic medication use and level of functioning covariates in patients.

Among patients, siblings, and controls, most participants did not change their smoking behavior from their previous assessments (89%, 86%, and 91%, respectively).

Over time, more participants quit than started smoking (patients, 7% vs 4%; siblings, 8% vs 6%; controls, 5% vs 4%, respectively).

Across all time points, the number of cigarettes per day increased by 0.4 (9.3) in patients, compared to siblings and controls who showed a decrease of 0.2 (5.3) and 0.2 (4.1), respectively.

In patients, starting to smoke was associated with an increase of self-rated positive, negative, and depressive symptoms, but not with QOL, compared with the overall decrease of symptoms in those who did not change their smoking status.

Coping Strategy

In contrast, in unaffected siblings and controls, there were no significant associations between starting to smoke and subclinical symptom frequency or quality of life.

After adding all covariates to the model, only the association between starting to smoke and an increase in positive symptoms remained significant (estimate 0.161 [SE, 0.077], P = .0381).

Post hoc analyses found that in the subgroup of patients for whom chlorpromazine equivalents could be calculated, smokers used significantly higher antipsychotic doses than did nonsmokers.

Significant associations were also found between smoking and symptom levels in the subgroups of patients who used clozapine and in patients who used olanzapine and other antipsychotics.

Vermeulen noted that the investigators “could not assess acute effects of smoking.”

She noted that smoking can be an “adverse stress-coping behavior strategy” and that, “with the right motivational interviewing strategy, we could try and help to learn to replace this by healthy coping strategies.”

She suggested several potential explanations for the high prevalence of smoking in individuals with psychosis, including the “shared vulnerability hypothesis.”

This means that there are “common genetic and environmental risks for developing both psychosis and nicotine addiction,” she said.

Another is that “smoking is a risk factor for developing psychosis.”

Concerns About E-Cigarettes

Commenting on the study for Medscape Medical News, James Scott, MD, conjoint association professor, School of Public Health, University of Brisbane, Australia, who was not involved in the study, said the findings “discount or disprove a long-standing theory that the reason there is such a high prevalence of smoking [among people with psychotic disorders] is to make them feel less distressed and anxious and improve their symptoms.”

Instead, this study “shows robustly that those people with schizophrenia who smoked had a worsening of their symptoms.”

He noted that “beyond the physical harm caused by smoking, we should really be concerned about smoking in people with schizophrenia because it affects their mental health, not only their physical health.”

Scott, who is the author of a recently published analysis suggesting a causal relationship between tobacco smoking and schizophrenia, suggested that nicotine may be the culprit because it has “significant effects on brain function.”

He added that a rising concern is the popularity of e-cigarettes, which are being marketed to nonsmoking young people as “safer” and are being flavored to make them more appealing.

“If nicotine predisposes vulnerable individuals to psychosis, it doesn’t matter whether it is in combustible or e-cigarette form,” he said.

Vermeulen emphasized that there is “a need for more research into this field to find the most plausible explanation for the high prevalence of smoking in individuals with psychosis, [so as] to tailor prevention and intervention programs.”

In an accompanying editorial, lead author Gemma M. J. Taylor, PhD, at the University of Bath, United Kingdom, notes that future research should focus on identifying mechanisms through which smoking affects mental health.

Determining whether the impact on mental health is mediated through nicotine or through some other constituent of tobacco smoke “will inform public health policy around the use of e-cigarettes in psychiatric populations,” the editorial authors conclude.

Only eight out of 100 on smoking cessation medications benefit from it


https://speciality.medicaldialogues.in/only-eight-out-of-100-on-smoking-cessation-medications-benefit-from-it/

Interventions for smoking cessation in patients admitted with Acute Coronary Syndrome: a review


Abstract

Tobacco smoking contributes to about six million deaths per year and is predicted to increase in the future. Several pharmacological interventions are used for smoking cessation. Trials using nicotine replacement therapy (NRT) in acute coronary syndrome (ACS) showed inconclusive results. Furthermore, three trials using bupropion in patients admitted with ACS failed to show improvement in smoking cessation compared with placebo. Interestingly, only one trial using varenicline was successful in achieving smoking abstinence in the acute setting. With regard to behavioural interventions, a meta-analysis found that telephone counselling was successful in both the acute and stable settings, with greater effect in the acute setting. The best results for smoking cessation were found in trials that used a combination of pharmacological and behavioural interventions. The objective of this report is to review the results of studies on interventions used for smoking cessation after an ACS.

Smoking Cessation Linked to HbA1c Rise in Type 2 Diabetes


For people with type 2 diabetes, quitting smoking may lead to a worsening of glycemic control unrelated to weight gain, a new study suggests.

The findings, from a large UK primary-care database, were published online April 29 in Lancet Diabetes & Endocrinology by Deborah Lycett, PhD, RD, clinical dietitian and principal lecturer in nutrition and dietetics at Coventry University, United Kingdom, and colleagues.
Of 10,692 type 2 diabetes patients who were current smokers on January 1, 2005, the 29% (3131) who subsequently quit for at least a year had an average 0.21% increase in their HbA1c levels (7.9% vs 7.7%) that wasn’t associated with changes in body weight or prescribing practices and that lasted 3 years post–smoking cessation.

“We suspected we would find the rise in HbA1c would have been explained by the weight gain that accompanies smoking cessation, but when we investigated this we didn’t find the evidence to support the theory in our data — which was surprising,” Dr Lycett told Medscape Medical News.

Findings Should Not Deter People From Quitting Smoking

However, the authors of an accompanying editorial question whether the study findings imply causation.

“We cannot infer from these results that stopping smoking causes increases in HbA1c concentrations because, despite adjustment for a range of clinical and demographic factors, the observational data presented might still be biased by residual confounding, both by indications for treatment and by lifestyle factors other than smoking status,” write Amy E Taylor, PhD, and colleagues, of the MRC Integrative Epidemiology Unit at the University of Bristol, United Kingdom.

Furthermore, severity of diabetes might affect patients’ success in stopping smoking, “so reverse causality cannot be ruled out,” they add.

Moreover, both the authors and the editorialists strongly emphasize that the findings should not deter clinicians from encouraging patients to quit smoking.
According to Dr Lycett, “These findings are about supporting patients to make a successful quit attempt, not to deter people from quitting. Rather, being aware of a rise in HbA1c allows both patients and clinicians to prepare for this and respond to it in order to have optimal diabetes control.” Such measures include optimizing statin and blood-pressure treatment and adjusting diabetes medications, she said.

Indeed, Dr Taylor and colleagues observe, “Establishing causality is unlikely to alter clinical messages about smoking cessation, because the benefits of quitting clearly outweigh any potential negative effects on health.”

Independent Effect

The figures analyzed by Dr Lycett and colleagues came from the Health Improvement Network (THIN) database, which includes electronic medical records from over 3.5 million patients in 546 UK primary-care practices.

The data set is fairly complete, since general practitioners are paid in part for their performance in caring for diabetes patients, including assessing their smoking status and encouraging quitting, as well as recording HbA1c and targeting a level less than 7.5%.

Adjustment for age, sex, diabetes duration, baseline body weight, statin prescription, and other factors did not significantly change the 0.21% difference in HbA1c between those who quit smoking and those who didn’t, which disappeared after 3 years.

The patients who stopped smoking gained an average of 4.8 kg. But for every 1-kg increase in weight there was only a 0.008% rise in HbA1c, “which would have a clinically negligible effect on HbA1c for most quitters,” the authors say.

The investigators looked to see whether the rise in HbA1c might be due to more medication being prescribed to smokers, but instead found the opposite: more of those who stopped smoking than continual smokers were on additional glucose-lowering medications at the end of follow-up than at the beginning.

For example, at the start of the study, 34.6% of continual smokers vs 32.0% of quitters were on metformin monotherapy. By the end of follow-up, 29.5% of continual smokers vs 22.1% of quitters were on metformin alone. At study start, 13.2% of smokers and 15.9% of quitters had begun taking injectable glucose-lowering treatments, while by the end those proportions were 21.1% and 29.5%, respectively.

Dr Lycett told Medscape Medical News, “The deterioration in HbA1c we found was small and temporary, over a period of 3 years, but the follow-up of the study was not long enough to determine what the long-term impact of this would be on macrovascular and microvascular complications.”

Teasing Out Causality

The lack of association with weight gain leaves the explanation for the findings unclear.

Dr Lycett said, “Even if weight gain is not the explanation behind this, it is possible that dietary change is, as we know that the preference for sweet-tasting food increases when people stop smoking, so this could potentially raise the glycemic load of their diet and their HbA1c. However, we as yet have no data to support this.”

In their editorial, Dr Taylor and colleagues suggest the use of causal inference methods to “provide more robust evidence” about the effects of smoking and smoking cessation on diabetes. Such methods might include assessment within the THIN database of physicians’ prescribing preferences for varenicline (Champix [UK], Pfizer) or nicotine-replacement therapy, since quit rates would be expected to be higher with varenicline.

Alternatively, they say, Mendelian randomization analysis using genetic variants related to smoking behavior could also help illuminate the impact of smoking on glycemic control, as well as reduce bias associated with body-weight–measurement error.

In any case, Dr Lycett told Medscape Medical News that the data on the cardiovascular benefits of quitting smoking for people with type 2 diabetes are well-established.

“This would suggest that the long-term benefits of quitting smoking definitely outweigh the temporary problems associated with it. However, it stands to reason that the optimal outcome would be to both quit smoking and to have good blood glucose control.”

Smoking cessation linked to diabetes control deterioration


A temporary deterioration in glycemic control, lasting up to 3 years, is linked to smoking cessation in adults with type 2 diabetes, according to recent study findings published in The Lancet Diabetes & Endocrinology.

“Knowing that deterioration in blood glucose control occurs around the time of stopping smoking helps to prepare those with diabetes and their clinicians to be proactive in tightening their glycemic control during this time,” Deborah Lycett, PhD, of the faculty of health and life sciences at Coventry University in the United Kingdom, said in a press release.

Deborah Lycett

Deborah Lycett

Lycett and colleagues evaluated data from 10,692 adult smokers with type 2 diabetes from The Health Improvement Network to determine whether diabetes control deteriorates temporarily after smoking cessation and whether weight change mediates the relationship. The study began on Jan. 1, 2005, and follow-up was conducted until transfer out of practice, death or end of follow-up on Dec. 31, 2010.

During follow-up, 55% of participants did not attempt to quit smoking (continual smokers), whereas 29% quit for 1 year or more (long-term quitters). During the first year of smoking cessation, researchers found an increase in HbA1c of 0.21%.

HbA1c levels rose at the time of quitting but gradually decreased as cessation continued in long-term quitters, whereas HbA1c rose gradually in continual smokers. By 3 years after cessation, HbA1c levels in quitters became comparable to those in continual smokers.

According to the researchers, weight changes did not mediate the increase in HbA1c levels.

“Stopping smoking is crucial for preventing complications that lead to early death in those with diabetes,” Lycett said. “So, people with diabetes should continue to make every effort to stop smoking, and at the same time they should expect to take extra care to keep their blood glucose well controlled and maximize the benefits of smoking cessation.”

Smoking cessation: Creating a quit-smoking plan


Create plan to cope with hurdles you may face as you quit smoking.

If you’re like many smokers and other tobacco users, you know you should quit — you just aren’t sure how to do it. Creating a quit-smoking plan may improve your chances of stopping for good. Having a plan helps prepare you for coping with the physical and emotional issues that often arise when you stop smoking, such as nicotine withdrawal and strong urges to smoke.

Deciding to quit smoking

Sure, you may be able to list plenty of reasons to stop smoking. You may be worried about the health problems related to smoking, the social stigma, the expense or the pressure from loved ones. But only you can decide when you’re ready to stop smoking.

You may spend a lot of time thinking about quitting smoking before you’re ready to actually do it. If you’re thinking about quitting, go ahead and pick a specific day to quit — your quit day — and then plan for it.

Picking a quit day

Pick a specific day within the next month to quit smoking. Don’t set your quit day too far in the future, or you may find it hard to follow through. But don’t quit before you have a quit-smoking plan in place, either. Having a day in mind can help you prepare for what to expect and line up helpful support. Pick a random day as your quit day, or pick a day that holds special meaning for you, such as a birthday or anniversary, a holiday, or a day of the week that’s generally less stressful for you.

What if you decide to quit smoking on the spur of the moment? Follow the quit-day advice and go for it.

Preparing for quit day

There’s no easy way to quit smoking. But planning for it can help you overcome the hurdles you’re likely to face. Here are steps you can take as you prepare for your quit day:

  • Mark the day. Make a big notation of your quit day on your calendar. It’s an important day in your life, so treat it like one.
  • Talk to your health care provider. If you haven’t talked to your doctor or health care provider yet about quitting smoking, do so now. Ask about stop-smoking counseling and medications. Using either counseling or medication improves your odds of success. And combining them is even more effective. If you’ll be using the prescription medication bupropion (Zyban) or varenicline (Chantix), you should start the medication at least a week or two before your quit day to give it time to begin working.
  • Tell people. Let family, friends and co-workers know about your quit day. Make them your allies. They can provide moral support. But tell them how they can be most supportive of your effort to quit smoking, so they are helpful and not just nagging.
  • Clean house. Rid your home, car, office and other places of your past smoking and tobacco supplies. Don’t keep any cigarettes on hand “just in case” — you might not be able to resist the temptation. Also, consider getting your teeth professionally cleaned as motivation to stay quit.
  • Stock up. Have on hand items that can substitute for the cigarette you’re used to having in your mouth, such as sugarless gum, hard candy, cinnamon sticks and crunchy vegetables.
  • Join up. The more support you have, the more likely you are to stop smoking successfully. Find local quit-smoking support groups. Many hospitals and clinics offer classes or groups. You can join online quit-smoking groups or programs. You can even get applications for your phone text messages or alerts to help you quit. Every state and many employers have a telephone quit line with professional coaches to help you develop your quit plan and support you through the process. Call 800-784-8669 (800-QUIT-NOW).
  • Reflect. If you’ve tried to quit smoking before, but took it up again, think about what challenges you faced and why you started again. What worked and what didn’t? Think about what you can do differently this time. For example, make a list of your triggers and how you will deal with them. Keeping a journal about your quit-smoking efforts may help you monitor feelings and situations that ignite your smoking urges.

Handling quit day

Getting through your quit day can be emotionally and physically challenging, especially if strong tobacco cravings strike. Try these tips to help manage your quit day:

  • Don’t smoke, not even “just one.”
  • Use nicotine replacement therapy if you’ve chosen that method.
  • Remind yourself of your reasons to stop smoking.
  • Drink plenty of water or juice.
  • Keep physically active.
  • Avoid situations and people that trigger your urge to smoke.
  • Attend a support group, counseling session or stop-smoking class.
  • Practice stress management and relaxation techniques.
  • Keep your hands busy by typing, writing, squeezing a ball or knitting.

Staying quit

With a quit-smoking plan to guide you, you’ll have resources that you can lean on when you quit smoking. The more resources you have in place — support groups, nicotine replacement, medications, coaching — the more likely you are to quit and stay quit.

Quitting Smokers Benefit From Both Phone and Web Services


States may improve tobacco cessation results by offering both telephone- and Web-based cessation services rather than one or the other, according to an article published in the January 2 issue of the Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report.

Mary Puckett, PhD, from the CDC’s Epidemic Intelligence Service, and colleagues describe the results of a survey CDC researchers conducted involving four states’ quitline service participants between July 2011 and February 2012.

Quitline participants in Alabama, Arizona, Florida, and Vermont responded to standard demographic and smoking-related questions via Web, mail, or telephone when they enrolled in a telephone- or Web-based program. Researchers administered a follow-up questionnaire 7 months later, asking whether the participants had smoked in the past 30 days and whether they used a single or both services.

Of the 5393 participants included in the final analysis, 2238 were telephone users, 1848 were Web users, and 1307 were dual-service users.

Dual-service users were almost 20% more likely to have abstained from smoking during the past 30 days than telephone users and about 50% more likely to have abstained than Web users. At 7 months’ follow-up, 38% of dual-service users reported abstinence from smoking, compared with 34% of telephone users and 29% of Web users.

Dual-service users were younger than telephone users but older than Web users (mean ages, 44, 47, and 40 years, respectively), had higher levels of education than telephone users but lower than Web users, and were slightly more likely to be white than black or Hispanic compared with telephone users but about 10% less likely to be white than Web users.

Sex and age made no significant difference.

However, participants living with a spouse were more likely to abstain from smoking if no other person living in the house was a smoker.

“[T]he availability and combined use of telephone-only and Web-based services might enhance quit success, but it might also reflect a greater commitment to quit among persons who use both services,” the researchers write.

Physicians who provide initial counseling to patients seeking to quit smoking can use these findings based on their patient population. Public health practitioners can use the information to determine the best smoking cessation programs to offer based on their patient populations, and to identify more effective programs for patients who have already tried unsuccessfully to quit smoking.

Limitations include possible lack of generalizability because only four states were involved whereas all states provide one or the other type of program, as well as the self-reported data. The study also did not include any tobacco products other than cigarettes.
The researchers conclude, “These findings suggest that access to and use of both cessation services might improve tobacco cessation success. Use of Web-based and telephone cessation services in combination provides a new tool for public health programs, such as CDC’s National Comprehensive Cancer Control Program, to prevent lung cancer. As such, tobacco and cancer control programs might choose to focus on implementation and improvement of both types of cessation services in their populations.”

Funding for smoking cessation campaigns – disclosures matter


An increasing awareness of the harms of tobacco smoking has coincided with the growth of a new industry – smoking cessation campaigns –  worldwide. With a high proportion of the world’s tobacco smokers, the Asia Pacific region is not an exception. A question of ethics now arises with regards to smoking cessation campaigns, which are being increasingly funded by pharmaceutical companies, in particular those with interests in nicotine replacement therapies (NRTs).

A key challenge faced by anti-smoking bodies is that there is a lack of funds for their campaigns. “There is still a lack of awareness of the risk factors associated with tobacco smoking, and smoking in general is often viewed as an issue of personal behavior, which is inaccurate,” said Dr. Carolyn Dresler, associate director for Medical and Health Sciences in the Office of Science at the US FDA Center for Tobacco Products Office. “It’s not just a behavioral problem we’re dealing with; it’s a chemical addiction – nicotine addiction – which is a serious disease.

“With regards to the relationship between the pharmaceutical industry and smoking cessation, to me it depends a little on the duplicity of the industries involved,” said Dresler. “In my opinion, the tobacco industry are convicted liars, but we cannot ignore that the pharmaceutical industry has had similar issues. However, the mission of pharmaceutical companies is ostensibly for good, whereas the product produced by the tobacco industry, when used as indicated, kills.”

Dresler noted that she was a former medical director of research and development for NRT products at a leading pharmaceutical company.

Market forces at play
“It is true that both smoking as well as smoking cessation are driven by market forces,” said Dresler, highlighting a recent case in which a US District Court in Washington D.C., ruled against the US FDA in favor of cigarette makers Lorillard Inc and Reynolds American Inc, who had sued the FDA in 2011, alleging conflicts of interest and bias by several members of the panel tasked with advising the FDA on tobacco-related issues. Their lawsuit specifically alleged that some committee members had conflicts of interest as they were paid expert witnesses, and possessed financial ties to pharmaceutical companies that manufactured smoking-cessation products.

In his ruling, which took place in July 2014, US District Judge Richard Leon said the FDA had erred in determining that the members did not have conflicts of interest and therefore, the agency’s appointment of those members was “arbitrary and capricious,” and tainted both the panel and its work. The FDA was ordered to reconstitute the tobacco panel and the use of its 2011 report on menthol cigarettes has been barred. [Available athttps://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2011cv0440-82. Accessed on 13 November 2014]

“It is difficult to separate conflict of interests and biases from something like smoking cessation, especially when there’s funding involved,” Dresler admitted. “This is because, as I mentioned, there is already very little funding being allocated for smoking cessation campaigns,” said Dresler. “When you put it up against something as large as the tobacco industry, with their large resources, and their ability to influence government and political decisions, it’s an uphill battle.”

Is there an ideal source of funding?
“If you have sources of funding from non-pharmaceutical organizations, such as non-governmental organizations or the health ministry, that would be best,” said Associate Professor Dr. Mohamad Haniki Nik Mohamed, Deputy Dean at Kulliyyah of Pharmacy at the International Islamic University Malaysia. “However, given the limitations, sometimes we do have to consider accepting funding from pharmaceutical companies to facilitate certain events. In such cases, the funding company should not become involved in the planning of the advocacy program – it should be completely independent.”

The worst thing to do, he stressed, would be to accept funding from the tobacco industry, for whatever purpose. Dr. Zarihah Zain of the Disease Control Disease, Ministry of Health Malaysia, agrees. “According to Article 5.3 of the Framework Convention on Tobacco Control (FCTC), parties to the Convention should not partner with tobacco corporations to promote public health, nor accept the tobacco industry’s so-called corporate social responsibility schemes, which are really just marketing by another name,” she said.

The Article 5.3 Guidelines also outlined transparency measures including, “Disclosure of current or previous work with tobacco industry by applicants for government positions related to health policy, and of plans to work for tobacco industry by former public health officials.” Also, “disclosure of tobacco industry activities, including: production, manufacture, market share, revenues, marketing, expenditures, philanthropy – with penalties for providing false or misleading information.

Cytisine vs Nicotine for Smoking Cessation


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