1. Braillon, Alain MD, PhD

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Smoking Cessation: Doing the Same Things Again and Expecting Different Results

DiSilvio and colleagues' review to improve care for smoking cessation is most welcome.1 Indeed, despite that in 1986 the Health and Public Policy Committee recommended physicians take an active role in counseling patient to quit smoking,2CNN recently dared to call a spade a spade with the title "US surgeon general says doctors aren't encouraging enough smokers to quit."3 However, robust comments are warranted.


First, considering the scope of the journal, it must be highlighted that nicotine withdrawal is a serious issue in the emergency setting: in a randomized, placebo-controlled study, nicotine replacement therapy (NRT) reduced agitation and aggression in smokers with schizophrenia.4


Second, the uncritical pledge for the "5 As" approach is a serious concern. Indeed, not only this approach has a low effectiveness but also it is flying in the face of common sense.


a. Why "Asking" about tobacco use? Most smokers have a specific odor and their fingers show their addictive behavior.


b. Why "advising" to quit smoking? Do you want they think you believe they are so dumb that they cannot understand the health warnings on the package?


c. Why "Assessing" readiness to quit smoking? All made serial cessation attempts, failing with suffering and despair. Very few of them expect to be able to get free from this severe addiction.



Instead of pointing the finger of blame on the victim of one of the worst addictive products, take time to reassure and explain. Why recommending only 10 minutes to care for smokers?1 Brief intervention is an unacceptable euphemism for I do not waste my time for this condition despite it kills 1 out of 2. Reassure by explaining that you do not require to quit but simply to: (a) implement the "belt and braces" strategy, which doubles the odds of quitting (nicotine patches with oral "rescue" formulations, spray or lozenge, to suppress occasional cravings); (b) increase NRT doses, without fear, until carving is suppressed (see later). Explain to overcome misconceptions, which preclude effective treatment, most smokers: (a) are not aware of the devastating effects of compensatory uptake of toxic by-products when trying to reduce smoking without patches; (b) are wrongly afraid of smoking with patches, being more scared of nicotine than CO or tar.


Further, DiSilvio and colleagues wrongly mixed motivational interview, a technique developed by Miller and Rollnick and the Transtheoretical Model with "5 stages of change" developed by Prochaska and DiClemente. Motivational interview is a most effective technique, which is based on ambivalence. It is robustly evidence based for promoting behavior changes in a wide range of health care settings.5 It needs training and time. The Transtheoretical Model is a concept that overlooks: (a) that different stages can coexist over a short period of time; (b) the "catastrophe theory," indeed, half of tobacco stops are not scheduled but brutally implemented and these unplanned stops are 2.6 times more often successful than those planned.6,7 No clinical data has evidenced any efficacy of the Transtheoretical Model. It only promises enduring and hellish processes leading to recurrences.


Last, NRT is rarely adequate:


a. The dose/response effect is the cornerstone for efficacy. For patients who smoke when waking up a 20-mg patch is almost never enough, and 30 to 40 mg with patches, not to account for oral forms, are needed to decrease craving. NRT is safe. High doses (90 mg/day) by 11 weeks were reached and well tolerated in 12 out of 20 Parkinson's disease patients participating in a trial about the effects of nicotine on motor symptoms.8 This does not preclude enduring misinformation such as "Nicotine ... lethal dose ranges from 10-60 mg" despite more than 500 mg of oral nicotine is required to kill an adult.9


b. Avoid nicotine gum as smokers' dentition is frequently poor, and when they can chew they do it continuously as a common gum. This produces saliva causing nausea or hiccup and therefore noncompliance. Prescribe various types of lozenges to allow choosing the one whose taste will offer the best compliance and explain it must not be "sucked" as wrongly advised.1 Lozenges must be kept under the tongue or between the cheek and the teeth to avoid producing saliva. For patients describing insomnia and nightmare, advise them to remove and to cut half of the patch in the evening.



Third, "hasten slowly," never "set a quit date within 2 weeks" as advised.1 The majority of smokers say they would prefer to quit by gradual cessation.10 Smokers will naturally quit without pain or efforts when craving has vanished and cigarettes being distasteful. Succeeding in adequately increasing nicotine doses to suppress carving may be a long journey for many patients. There are no reasons for putting pressure on them unless you look for a programmed failure. Do pain doctors set their patients a date for being pain free?


Fourth, the American Thoracic Society is the sole organization to recommend varenicline as first line (strong recommendation, moderate certainty in the estimated effects).11 I prefer to use it as a second line when patients cannot adequately use NRT, but I must confess that in the real-life setting varenicline may be more effective than NRT, as most professionals fail to adequately explain that gradual quitting is not dangerous when using NRT.


Fifth, certainly the USPSTF concluded that there is insufficient evidence to recommend e-cigarettes for smoking cessation. However this is too shy, indeed: (a) vaping is not quitting; (b) the "harm reduction" motto has been previously used for filters and then after for light and low-tar cigarettes with devastating consequences; (c) e-cigarettes cause lung adenocarcinomas and bladder urothelial hyperplasia in mice.12 The International Agency for Research on Cancer defines Group 2A carcinogen as "limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals."


-Alain Braillon, MD, PhD


Amiens, France




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12. Tang MS, Wu XR, Lee HW, et al Electronic-cigarette smoke induces lung adenocarcinoma and bladder urothelial hyperplasia in mice. Proc Natl Acad Sci USA. 2019;116(43):21727-21731. [Context Link]