How to Stop Smoking

1. Don't smoke.
2. See 1.

This is essentially what Simon Chapman and Ross MacKenzie suggest in a provocative PloS Medicine paper, The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences.

Their point is deceptively simple: there is lots of research looking at drugs and other treatments to help people quit smoking tobacco, but little attention is paid to people who quit without any help, despite the fact that the majority (up to 75%) of quitters do just that. This is good news for the pharmaceutical industry and others who sell smoking-cessation aids, but it's not clear that it's good for public health.

As they put it,

despite the pharmaceutical industry’s efforts to promote pharmacologically mediated cessation and numerous clinical trials demonstrating the efficacy of pharmacotherapy, the most common method used by most people who have successfully topped smoking remains unassisted cessation ... Tobacco use, like other substance use, has become increasingly pathologised as a treatable condition as knowledge about the neurobiology, genetics, and pharmacology of addiction develops. Meanwhile, the massive decline in smoking that occurred before the advent of cessation treatment is often forgotten.

Debates over drugs, or other treatments, tend to revolve around the question of whether they work: is this drug better than placebo for this disorder? Chapman and MacKenzie point out that even to frame an issue in these terms is to concede a lot to the medical or pathological approach, which may not be a good idea. Before asking, do the drugs work? We should ask, what have drugs got to do with this?

Their argument is not that drugs never help people to quit; nor are they saying that tobacco isn't addictive, or that there is no neurobiology of addiction. Rather, they are saying that the biology is only one aspect of the story. The importance of drugs (and other stop-smoking aids like CBT), and the difficulty of quitting, is systematically exaggerated by the medical literature...

Of the 662 papers [about "smoking cessation" published in 2007 or 2008], 511 were studies of cessation interventions. The other 118 were mainly studies of the prevalence of smoking cessation in whole or special populations. Of the intervention papers, 467 (91.4%) reported the effects of assisted cessation and 44 (8.6%) described the impact of unassisted cessation (Figure 1).... Of the papers describing cessation trends, correlates, and predictors in populations, only 13 (11%) contained any data on unassisted cessation.

And although pharmaceutical industry funding of research plays a part in this, the fact that medical science tends to focus on treatments rather than on untreated individuals is unsurprising since this is fundamentally how science works:

Most tobacco control research is undertaken by individuals trained in positivist scientific traditions. Hierarchies of evidence give experimental evidence more importance than observational evidence; meta-analyses of randomized controlled trials are given the most weight. Cessation studies that focus on discrete proximal variables such as specific cessation interventions provide ‘‘harder’’ causal evidence than those that focus on distal, complex, and interactive influences that coalesce across a smoker’s lifetime to end in cessation.

Overall, it's an excellent paper and well worth a read in full (it's short and it's open access). Of course, it is itself only one side of the story and many in the tobacco control community will find it controversial. But I think Chapman and MacKenzie's is a point that needs to be made, and point applies to other areas of medicine, especially, although not exclusively, to mental health. This week, British social care charity Together told us that

Six out of ten of people have had at least one time in their life where they have found it difficult to cope mentally... stress (70%), anxiety (59%) and depression (55%) were the three most common difficulties encountered by the public

Which was not still not quite as good as rivals Turning Point who last month said

Three quarters of people in the UK experience depression occasionally or regularly yet only a third seek help

These were opinion surveys, not real peer-reviewed science, but they might as well have been: the best available science says that if you go and ask people, 50-70% of the population report suffering at least one diagnosable DSM-IV mental disorder in their lifetime, and that the majority receive no treatment at all. This leads to papers in major journals such as this one warning that "Depression Care in the United States" is "Too Little for Too Few."

But we don't know whether these tens of millions of cases of untreated "mental illness" should be treated, because there is basically no research looking at what happens to such people without treatment. On the other hand, the very fact that they aren't treated, and yet manage to hold down jobs, relationships and so forth, suggests that the situation is not so bad.

Of course we must never forget that depression and anxiety can be crippling diseases, but fortunately, such cases are at least comparatively rare. By using the word "depression" to cover everything from waking-up-at-4-am-in-a-suicidal-panic-melancholia to feeling-a-bit-miserable-because-something-bad-just-happened, it's easy to forget that while clinical depression is a serious matter, feeling a bit miserable is normal and resolves without any help 99% of the time. Even though there are no published scientific studies proving this, because it's not the kind of thing scientists study.

Incidentally, this issue is a good reminder that there's no one big bad conspiracy behind everything. With smoking, Big Tobacco find themselves in direct opposition to Big Pharma, like in From Dusk Till Dawn when the psychopaths fight the vampires. With depression, the people who are quickest to decry the widespread use of antidepressants often seem to be the ones who are most keen on the idea that depression is common and under-treated, perhaps because it allows them to recommend their own favorite psychotherapy. Big Pharma hands the baton to Big Couch in the race to medicalize life.

Chapman S, & MacKenzie R (2010). The global research neglect of unassisted smoking cessation: causes and consequences. PLoS medicine, 7 (2) PMID: 20161722