Dear Editor,

The concern for improving smoking cessation in pregnant women1 is most welcome but deserves comment, despite rightly stressing the mandatory needs for: a) trained providers or specialized services; and b) the belt-and-braces strategy, combining psychological support with pharmacotherapy (nicotine substitutes using patches plus lozenges)1.

Indeed, the present state of affairs is a ‘shipwreck’: a) in the US, only 1 in 5 pregnant smokers is offered nicotine substitutes, and 1 in 4 does not receive any intervention to quit2; and b) In France, during the World No-Tobacco Day, in the main entrance of a university hospital, midwives ran a booth with the banner: ‘Acupuncture, an alternative to nicotine replacement therapy in smoking cessation3. As a matter of fact, since 2017, nicotine substitutes packages have a big red label that reads ‘nicotine + pregnancy = danger’ and a pictogram with a black subtitle that reads ‘do not use during pregnancy unless no therapeutic alternative’. Worse, the French Department of Health flied in the face of evidence and common sense, even rejected pledges by the Institute of Medicine and NGOs to withdraw these devastating warnings4. Moreover, warnings are ‘icing on the cake’ as too many professionals overlook: a) the deleterious effects of compensatory uptake of harmful by-products (CO, tar, etc.) when trying to quit without nicotine substitutes5; and b) that smoking with nicotine substitutes does not cause an increase in nicotine concentration, and they overestimate by a factor of 10 the nicotine deadly dose6. Frequently, at follow-up visits my patients report that their pharmacists warned them against smoking with patches or challenged my prescriptions as being too high; with my warnings to pharmacist and medical regional councils usually being ignored.

However, the International Health Maintenance Organizations’ 5 As (Ask, Advise, Assess, Assist, Arrange) approach is flawed, it is the opposite of the motivational interviewing that is rightly promoted by Diamanti et al.1. No need to Ask, look at fingers and smell. Advising is pointing the finger of blame, as though these women are dumb; advising to quit can only decrease further an already poor self-esteem. Why Assessing readiness to quit? Tobacco is the worst drug and no smoker expects to be able to quit. All smokers fear quitting, having made a series of attempts, with always the same results: suffering and despair.

First, one needs to simply reassure and reassure: ‘I do not require you to quit, but only to take the treatment of smoking with patches, which is less dangerous than without, and do increase the dose as needed’; craving and desire to smoke result in pain and suffering due to lack of nicotine; ‘Hasten slowly, you will naturally quit when there is no craving and cigarettes become distasteful’. Indeed, fixing a quit-date is a programmed failure! Can doctors set a date for their patients to become pain free? Second, one needs to educate smokers to self-increase the dose of nicotine substitutes (patches and faster-acting forms) until the craving is suppressed and cigarettes become distasteful. Third, there is no evidence yet for the efficacy of e-cigarettes versus proactive evidence-based treatment. Switching to vapor does not qualify as cessation7; and e-cigarette smoke in mice produces DNA damage, inhibits DNA repair, causes lung adenocarcinomas, and bladder urothelial hyperplasia8.

Proctor9 created the term ‘agnotology’ (the study of culturally induced ignorance or doubt) to highlight the misrepresentation of facts by the tobacco industry to fool ordinary people. This seems to be a case of the ‘pot calling the kettle black’.