Reply to Ackermann.

Abstract

Evan Ackermann’s (2015) response on behalf of the Royal Australian College of General Practitioners (RACGP) to our article ( MacKenzie and Rogers, 2015 ) largely reiterates previous criticisms levelled by the College ( Groombridge, 2015 ). The dominant message of the Guidelines is to advise pharmacotherapy for cessation attempts, and it is clearly stated that ‘pharmacotherapy should be recommended to all dependent smokers who express an interest in quitting except where contraindicated' (p. 27). While Ackermann claims that the Guidelines do, in fact, provide advice on non-pharmacological cessation approaches, he fails to mention that such guidance is moderated by reference to the need for medication. This is particularly explicit in the Guidelines’ acknowledgement (p. 17) that ‘the most common method used by most people who have successfully stopped smoking is unassisted cessation', a point that is immediately undermined by the statement that ‘more than half of all smokers making quit attempts are using some form of help, mainly medications'. A later reference to the many smokers who attempt to quit unassisted notes that this approach has ‘a low likelihood of succeeding' (p. 41). The Guidelines’ focus on pharmacotherapy-assisted cessation, and the corollary dismissal of the fact that most ex-smokers have quit unassisted, led us to investigate the evidence cited in the RACGP guidelines. As described in our methods, we found that the majority of studies cited in support of claims for the greater efficacy of medicated cessation, including those in systematic reviews, were randomized control trials (RCTs) funded by pharmaceutical companies. The concerns regarding bias in cessation RCTs, and in industry-funded clinical research more broadly, are well-known. We identified potential conflicts of interest among the authors of the Guidelines. Ackermann is correct that at least some information about authors’ industry links were declared in the Guidelines. This level of transparency is commendable but does not preclude concerns that the potential for conflict remains. Disclosure is necessary, but far from sufficient in adequately addressing the potential bias associated with conflicts of interest. The defence that the RACGP recommendations are consistent with guidelines from the USA and the UK touches on a key point of our article. Specifically, the message that pharmacotherapy is essential to successful cessation at population level has gained unwarranted global credibility that is not supported by research beyond tightly controlled RCTs that are often funded by the pharmaceutical industry. The aim of our article is to highlight the fact that recommendations made by peak medical bodies like the RACGP have significant implications for cessation advice offered by GPs and other health professionals, and for the general public who increasingly turn to Internet resources for medical information. Such recommendations should reflect the full range of literature and evidence available, something these guidelines fail to do. Finally, the RACGP released revised guidelines in 2014, after we had submitted our paper for peer-review. We have not had the opportunity to do a thorough assessment of this edition. However, the summary of changes included in the 2104 publication make no mention of additional information on unassisted quitting, or of a decreased focus on pharmaceutical-assisted quit attempts.