Business- and Medical-model industries controlling public healthcare funds send patients wanting to stop smoking to medical visits for prescription medications and nicotine replacement therapy (NRT), like nicotine patches, to reduce urges to smoke, but neither are supported by research as significantly effective and both encourage patient belief in the invalidated medical model of addiction, that belief a key predictor of continued problem substance use.
Health costs of smoking eclipse those of almost all other compulsive substance use problems, and worse, include direct links to the opioid crisis. Response to the national opioid crisis generally gets it backwards. Marijuana use, often disallowed for patients with chronic pain and/or prescription opioid use by healthcare providers, is supported by research as providing benefit in managing chronic pain and reducing dependence on opioid medications; in contrast tobacco use, long ignored or enabled by medically-managed programs, is established by research as contributing to development of chronic pain syndromes and as worsening perception of chronic pain.
Extensive research supports the role of tobacco use in etiology (cause) of chronic pain conditions including fibromyalgia, lower back pain, rheumatoid arthritis and in exacerbated perception of chronic pain(1)
Additional research points to increasing risk of continued or return to problem use of substances including opioids due to tobacco use – acting as a “gateway drug” for opioids (2-4)
Recognition of the research-based links among tobacco use, chronic pain, and problem opioid use has led progressive, evidence-based programs to begin making tobacco cessation services a key component of addressing the opioid crisis(2,4)
There are many ways that research – especially when interpreted by professionals and writers out of scope of competence to analyze and think critically about research results, that is, without training or experience as researchers – can be distorted, invalid, with illegitimately drawn conclusions and potentially lethal consequences One of those ways is related to the distinction between statistical significance and clinical significance.
Statistical significance refers to the method – essentially the purpose and value of statistical testing – by which a probability value (for example P=.02) represents the confidence of drawing the conclusion of a true (not due to chance in the experiment) benefit, or difference between treatment and no treatment as indicated by the chosen measure for a difference. A probability value of P=.02, for example, would indicate the likelihood of the measured difference not being “real” as only 2%, so we would have relatively high confidence in it being a real difference. It does not tell us about the magnitude of the difference or whether the difference can reasonable be expected to be gained by smokers under realistic natural conditions in their natural settings (“external validity”).
Those magnitudes, or size of benefit, for Nicotine Replacement Therapy (NRT) when treatment results in a statistically significant difference, and for the other medications, are quite small, for example in this study a benefit to 3%, or 3 of every 100 people treated with NRT. Clinical significance typically in these studies is ignored, masked by focus on the statistical measures like odds ratios, confidence intervals, probability (P) values.
If a statistically significant clinical trial outcome established benefit from a type of chemotherapy for cancer for 3% or 5% of treated patients, would the treatment be recommended and provided to patients? And paid for using public healthcare funds? Or instead would recommendations be to use other treatments with greater clinical significance and to factor quality of life and negative side effects of the treatment into decision-making and recommendations?
Apart from the cost in public funds to provide “treatments” for smoking cessation with benefit to only 3 – 5% of patients treated, are there additional costs that would outweigh the very small probability of benefit from the medical-model treatment?
– Additional studies (5-7) provide evidence of no benefit for smoking cessation from NRT.
– Studies routinely combine medication in treatment groups with counseling, the combination typically resulting in more positive outcomes than for the medication alone, and disallowing conclusions about benefit due to the medication alone.
– Individual counseling is effective for smoking cessation, with no indications of lack of benefit, and greater clinical significance than for NRT and medications, one review attributing an increase from 7% success with brief counseling support to 10 – 12% with individual counseling. Those results are for standard counseling for substance use, established as generally ineffective. Use of therapies supported by research and theory as effective would predict larger positive outcomes.
Lack of clinically significant benefit from NRT and medications for smoking cessation was predictable based on evidence available related to compulsive substance use and its treatment.
Compulsive substance use is not a disease or medial condition of any type, instead the behavioral symptom of attempts to manage inner distress. We would not expect medical treatments for entirely non-medical problems to be effective.
More specifically, the presumed effect providing benefit for NRT and the medications is moderation or elimination of urges, or cravings, in the weeks after quitting. But research on course of abstinence and relapse after stopping compulsive use of substances establishes that urges per se are not significant in predicting relapse, instead other factors.
Lack of skills for coping with stress
Belief in the disease model of addiction
In this survey relapsers to alcohol, tobacco, other substances reported on their experience of antecedents, or “triggers” to use again
“Inner states”, not urges or cravings per say, were reported by 58%. Of those: negative emotions accounted for 37%; urges for 7%
Interpersonal stressors were reported by 42%. Of those: 15% reported conflict; 24% reported social pressure
There were no reports of a sense of “loss of control” or of a brain with baseline urges or compulsions untied to inner or environmental stressors
In summary, results of these surveys highlighted the importance of mood states versus impulses with lack of control, and of situational, environmental stressors especially social stressors.
There were no effects of urges or severity of smoking (HSI) on relapse risk over days 1 – 30 after stopping “during which nicotine dependence would be most likely to influence quitting success”
Self-efficacy (= self-confidence) had a strong effect (statistically significant), through duration of study, day 1 to 3 years
There was a negative correlation, statistically significant, between self-efficacy and frequency of urges – the stronger a participant’s beliefs about being empowered and competent in making changes, the fewer urges were experienced
In summary, results of this survey disconfirmed urges or impulsivity as a factor, even over the first 30 days after stopping, when the diseased or “hijacked” brain would be most vulnerable to those factors, instead confirmed deficiency in self-confidence, or belief in one’s ability to stop smoking as a strong factor, consistent with other findings that establish belief in having a chronic, relapsing disease as a factor predicting relapse.
These results establish the importance of two key factors in predictions of long-term effectiveness versus harm to smokers receiving treatment for compulsive tobacco use – the effects on sense of self-efficacy, a predictor of success in stopping substance use, and effects on belief in the fictional disease model of compulsive substance use, predicting relapse.
– clinically insignificant or lack of benefit from the treatments
– introduction or reinforcement of belief in the fictional disease model of substance use, a predictor of relapse
– and diminished self-efficacy, treatment consisting of a passive medication intervention as a substitute for focus on patient investment, collaboration, and active changes in behaviors and self-management of internal stressors and environmental stressors
+ small but clinically significant benefit from treatment, no evidence for lack of benefit
+ gains in self-efficacy inherent in patient-centered treatment and cognitive and behavioral therapy interventions
+ avoidance of pathologizing of behaviors or patient, no reinforcement of disease model
They do not likely realize that some 70% of complaints in primary care settings are idiopathic, that is, with no identifiable physical or biomedical cause or treatment.
They may not realize that the assurances of medical fixes for “addiction” are based on invalidated, fictional medical models and are without support.
Or that the false assurances of effectiveness of and safety of opioid pain medications for chronic pain were never supported by evidence, were pure fiction from the beginning.
that compulsive substance use is a medical condition or disease state
that there are effective medical treatments for substance use
decreasing their motivation to accept and make the behavioral and social changes required to overcome compulsive substance use
increasing risk of return to problem substance use (“relapse”) based on belief in the invalidated disease model of substance use
decreasing their motivation and inclination to access evidence-based psychotherapies for substance use and mental health problems
increasing risk of using ineffective or harmful biomedical interventions for entirely non-medical problems: from smoking and other substance use problems, to depressed or anxious mood, to chronic pain – generating an opioid crisis
Despite the evidence, the medical/pharmaceutical industry, with the cultural capital to arbitrarily create “knowledge” and public messaging and understanding about healthcare, is highly successful in ensuring that Americans will be misled to continue to access ineffective medical treatments for non-medical problems and that profits and power will be protected.
Costs of harm to public health include not only direct costs of ineffective treatments, but costs tied to the links among tobacco use, chronic pain, opioid misuse, and the associated costs of problem opioid use.
Talking about and challenging these scams, these threats to public health, requires taking back control of language, of understanding, and of cultural capital to support and protect public health, to begin to use language that constructs true and accurate pictures of American healthcare. Language that penetrates the sheen of decency, expertise and authority that helps perpetuate harm. Language like