Before turning to the focus of this book – how most ex-smokers stop smoking unassisted and the censorious reception that profane, heretical broadcasting of this too loudly can attract – I want to provide a brief overview of parallels with other dependencies or addictions. So, in this chapter, I will summarise the evidence about how the many people who once had other problem dependencies but no longer do, moved away from the fabled clutches of these without treatment or any formal support.

Within the addictions research field there has been a small group of pioneers of this research who have studied the natural histories of various substance and behavioural dependencies. They have shone light on what the research literature says about this phenomenon which is variously referred to as spontaneous remission, natural recovery, maturing out and unassisted change or cessation. These pioneers include Patrick Biernacki (Biernacki 1986), George Vaillant (Vaillant 1995), Jim Orford (Orford 1985), Harald Klingemann, Linda and Mark Sobell (Klingemann, Sobell et al. 2010) and Stanton Peele (Peele 1989). As we will see, there are some similarities here with what happens with the major phenomenon of unassisted recovery from smoking.

There have been several reviews of the early literature on unassisted remission from problematic substance use. Rossana Mariezcurrena published a narrative, descriptive review of the available literature in 1994, with sections on alcohol, drugs, tobacco and obesity (Mariezcurrena 1994). Walters’ 2000 review of the quantitative literature on unassisted remission across several fields of substance dependence reported on just 11 papers, some of which covered more than one dependency (Walters 2000). He summarised a table in his paper on the prevalence of spontaneous remission in these dependencies as being “4.3% to 56.4% … attributed to differences in the length of follow-up (range 1 to 27 years) and the time frame used to determine spontaneous remission (range 6 months to 3 years). The mean general prevalence of spontaneous remission for studies utilising a broad definition of remission was 26.2% in follow-ups averaging 5.3 years, with a mean rate of 31.4% for alcohol (n = 8 studies), 37.9% for illicit drugs (n = 2), and 13.4% for tobacco (n = 5).”

A 2010 systematic review of studies published between 1990 and 2009 on unassisted remission from amphetamines, cocaine, cannabis and opioids found just 10 studies of opioid and three for cannabis dependence. Definitions of remission varied and most did not clearly assess remission from dependence. Using conservative criteria for remission, rates varied between cannabis dependence (17.3%), amphetamines (16.4%), opioid (9.2%) and cocaine dependence (5.3%) (Calabria, Degenhardt et al. 2010).

Alcohol

In Australia in 2019, 6.7% of the adult population reported drinking more than 11 standard drinks on the one occasion, with 30% in the 18–24 year age group having done this (and 14.6% having done this at least monthly) (Australian Institute of Health and Welfare 2020f). That this measure of harmful drinking declines dramatically with age, suggests that a very large number of people who regularly drank heavily early in their drinking histories mature out of it. Here’s a selection of research support for that proposition.

In 1989, Statistics Canada conducted a random-digit-dialling telephone survey of 11,634 people living in 10 Canadian provinces, called the National Alcohol and Drugs Survey. A 78.7% participation rate was obtained. In 1993, the Institute of Social Research at Toronto’s York University conducted a similar survey. Both surveys assured respondents of anonymity and reported data on the proportion of drinkers aged 20 and over who declared that they had experienced problem drinking but had recovered for more than a year. Linda Sobell and colleagues summarised the findings of the two surveys in a 1996 paper (Sobell, Cunningham et al. 1996).

The two surveys found that 75.5% (in the national survey) and 77.7% (in the Ontario survey) of those who had experienced but resolved problem drinking for more than a year had done so without any formal help or treatment. The definition of help here included attendance at Alcoholics Anonymous or any other support group; seeing a psychologist, psychiatrist or social worker; attending a psychiatric hospital; receiving help via a minister, priest or rabbi; receiving help from a doctor or nurse; attendance at a hospital or emergency department, alcohol/drug-addiction agency, a detoxification centre or halfway house; or attending a drink-driving referral program.

These were the first times that large-scale population data on this plainly widespread phenomenon – three in four recovered problem drinkers – had been gathered and reported. But as we will see below, unassisted recovery had been described by clinicians and those following the life courses of alcoholics since at least 1953 (Lemere 1953). Below are summaries of the key findings of a selection of these.

Roizen et al (1978) reviewed the literature available at that time on problem drinkers who had declined or been refused treatment, concluding, “In spite of the climate of opinion in which spontaneous improvements are often regarded as rare … remission in the sense of six months of abstinence can be expected in 15 percent of cases” (Roizen, Cahalan et al. 1978, 201).

A small 1979 Scottish study of 19 “definite alcoholics” and 41 “problem drinkers”, all without current drinking problems, found none reported receiving treatment of any sort, but attributed their change to life events like marriage, job change or illness, or to family or doctor advice or improvement of financial problems (Saunders and Kershaw 1979).

Similar factors were reported in a Texas study by Tuchfeld of those who’d given up drinking without any formal treatment (Tuchfeld 1981). Tuchfeld was careful to conclude that describing cessation of alcohol as “spontaneous” risked missing the importance of “internal psychological commitment” to stopping drinking being “usually activated by social phenomena … by significant alterations in social and leisure activities”. Indeed, much of the research literature emphasises the same key factors in those who successfully end their dependencies without professional help.

George Vaillant’s pioneering 1983 book The natural history of alcoholism and its 1995 update The natural history of alcoholism revisited (Vaillant 1995) contain a great deal of information on the life-course of alcoholism and problem drinking. His 1995 revised book reviews all known longitudinal studies at the time of treated and untreated alcoholics and explores in great depth difficulties of studying those with this problem.

Loss to follow-up is a major problem in researching people with serious alcohol problems. In cohorts followed for many years, the often chaotic lives of alcoholics caused by frequent intoxication, job losses, incarceration, hospitalisation, homelessness, poverty and early death all greatly confound any strong conclusions being drawn about the proportions of alcoholics who ever recover, about what factors predict continuing alcoholism and what predicts those who become abstinent or asymptomatic drinkers after earlier alcoholism.

This may suggest that investigation of unassisted recovery with alcoholics may be biased by over-representation of those in follow-up research whose lives may have been somewhat less chaotic and disrupted than those who failed to recover.

Relapse is also a major problem in investigating abstinence after alcoholism, with long-term follow-up of abstinent former alcoholics being very uncommon. Vaillant reports a study with a mean eight-year follow-up which found that 45% of alcoholics relapsed after two years of abstinence, but only 9% after six years (Vaillant 1995, 235).

His review of 10 long-term follow-up studies concluded that “the best outcomes were from [three] untreated community samples … the worst outcomes, if one includes deaths, were received by alcoholics who received inpatient treatment” while noting that the latter “represented a more severely ill population with poorer prognosis”. They were also older, and therefore more likely to die.

In summary, Vaillant’s review identifies so many fundamental caveats about differentiating the progression of treated and untreated alcoholics that nowhere in his 446-page book does he ever come close to making any definitive statements that might resolve the question.

A 2019 systematic review of international research on untreated remission of alcohol problems found 124 estimates from 27 different studies, with the authors finding large variations across these studies in the ways in which both “treatment” and alcohol problems were defined, making it problematic to come up with any “across all studies” figure for untreated remission (Mellor, Lancaster et al. 2019). The same authors later conducted an online survey on a Facebook-recruited convenience sample of 719 people who had resolved an alcohol problem in Australia. Almost half (49.8%) of all people who resolved their alcohol problem did so without any access to alcohol treatment (specialist alcohol treatment, mutual-aid services or digital support services). However, this estimate dropped to 12.8% when accessing mental health treatment was included in the definition of “treatment” (Mellor, Lancaster et al. 2019).

Opiates

Perhaps more than any other category of drug, opiate narcotics have a popular reputation as being perishingly difficult to stop using once a person develops a lasting narcotics addiction. But as we shall see, there are a huge number of former narcotic-dependent people who have permanently stopped using these drugs, often after prolonged periods of addiction.

Patrick Biernacki’s 1986 book Pathways from heroin addiction: recovery without treatment (Biernacki 1986) was an early myth-busting review of the hitherto largely unexplored phenomenon of people moving away from heroin use without any professional assistance. He commenced his book by asking a similar question to the one I began exploring for tobacco around the same time (Chapman 1985, Chapman 1986):

Biernacki noted the very similar way that heroin dependency was viewed to alcoholism at the time (and still is very much today) by addiction theorists and therapeutic practitioners:

Biernacki’s book explores information provided to his research team by 101 former opiate-dependent people who had been addicted for at least a year, and who were located and interviewed across two years from August 1978. Duration of their narcotics use ranged from one to two years, and up to 15 or more, with the number of years since last use also covering those time periods. Because of the stigmatised, illegal and subterranean nature of narcotic use in the USA at that time, his subjects were located by snowball sampling where those interviewed recommend others to be approached to take part (Biernacki and Waldorf 1981), often via contactable former narcotics users who were or had used treatment facilities. The challenges of obtaining the subjects for interview are fully described in an extensive appendix to the book.

He explores his informants’ resolution to stop using narcotics, their steps to break away, why they chose not to avail themselves of any treatment or support program (all 101 had never used such services), moving away from the world of narcotics using friends and acquaintances, and establishing new relationships, interests and identities, and becoming “ordinary”.

As with Vaillant’s book on recovery from alcoholism, because of the inherent difficulties in locating former narcotics users and obtaining their consent to be involved in research, Biernacki’s study does not allow any conclusions to be drawn about how common “natural” unassisted recovery is with narcotics. But it most certainly shows that natural recovery from narcotics is a real phenomenon, understudied as much then as it continues to be today.

American armed forces heroin users after the Vietnam War

One of the most famous of all studies in the natural recovery field is that by Robins, Davis and Nurco of American armed forces personnel who served in Vietnam and used narcotics (mainly heroin and opium) (Robins, Davis et al. 1974). The study involved interviewing and urine testing for narcotics on a sample of 470 enlisted personnel drawn from 13,760 who had returned from Vietnam in September 1971. Nineteen percent of these men were still enlisted when being interviewed, with the remainder being at the time civilians for an average of seven months.

Forty-three percent of those interviewed had used narcotics in Vietnam, with 46% of these saying that they had been addicted. But only 7% said they were still addicted since their return to the USA, with only 1% having positive urines. Of those who were “narcotic virgins” on arrival in Vietnam, more than two-thirds stopped all narcotics use when they left Vietnam.

Unfortunately, the paper says nothing about how these narcotics users stopped using, but there is also no mention of any treatment facilities provided either in Vietnam or by the armed services for those who returned to the US who may have had addiction problems. This absence may suggest that those who did stop using narcotics on their return from Vietnam mostly recovered without assistance.

Cannabis

I went through my 20s in the 1970s. There was a lot of cannabis being smoked in that decade. I smoked it socially about once every couple of weeks for perhaps five or six years and associated with few people of my age who didn’t. When I started taking my career seriously, as had happened with my cigarette smoking I decided I didn’t want to continue using dope and have not touched it in decades. Smoking dope wasted a lot of productive time which I increasingly valued. I also began to see many stoners as being very limited in their conversation and didn’t want to feel that I might seem like that to others as well. Researchers on this well-recognised phenomenon have long referred to it as “maturing out” (Winick 1962).

As with smoking cigarettes, I subsequently found across the next decades that my story of smoking dope and then stopping uneventfully was very common and unremarkable. For many, smoking dope was something you did when you were young but then you “grew out of it” as you took on more responsibilities in study, work and your family life. But, as with smoking, I was never a heavy user.

So much for an anecdote, but what does the research literature have to say about the natural history of cannabis use?

The Australian Institute of Health and Welfare’s (AIHW) 2019 National Drug Strategy Household Survey found 32% of adults reported ever having used cannabis, but that only 11.6% reported using it in the past 12 months (Australian Institute of Health and Welfare 2020b). Cannabis use decreased from a peak in the 30–39 year age group (47.2% any lifetime use; 13.7% use in the last 12 months; 7% use in the last month; 4.7% use in the last week) to (respectively) 8.9%, 2.9%, 1.6% and 1.3% in the 60+ age group, the youngest of whom would have been born in 1959. While there are certainly birth cohort differences in cannabis use in these two age groups, the reductions are also compatible with the maturing-out hypothesis. In over 40 years working in Australian public health, I have never heard of anything but small, fringe “treatment” services for quitting cannabis use. The overwhelming majority of former users almost certainly stopped getting stoned without help.

Beyond observations like those above about many Australian cannabis users maturing out of use as they aged, the research on questions about both why and how cannabis users stop is disappointingly sparse and thin, beyond work that notes correlates of different patterns of or changes in use, such as changing neighbourhood and friendship networks (Pollard, Tucker et al. 2014), transition to adulthood (Schulenberg, Merline et al. 2005, Kelly and Vuolo 2018), getting married (Leonard and Homish 2005), onset of pregnancy (Chen and Kandel 1998) or having a psychosis-like experience (Sami, Notley et al. 2019). A 2019 German retrospective cohort study of 6,467 current or former cannabis users aged 15 to 46 years (mean age 22.5) who had used the drug for at least three years found 16.3% had not used it in the previous year. No information on why they stopped or how they went about it was reported, and the young age of most of those in the study means we know nothing about transitions past an age when cannabis use is still at its peak (Seidel, Pedersen et al. 2019).

Missing from the literature is any substantial examination of motivations to stop using cannabis or of how users went about stopping. Indeed, intense searching of research publication databases failed to find a single paper or even a section within a paper examining or even speculating about how millions of people who once used cannabis but no longer do so transitioned to non-use. Perhaps the answer lies in something unstated but almost taken for granted: that for many, regular cannabis use in teenage and early adult life is something that people grow out of with few difficulties or much effort, and that most users do not have a dependency problem.

Problem gambling

“Gambling disorder” has been classified by the American Psychiatric Association as a behavioural disorder since 2014. Nine criteria are set out, and for diagnosis to be met at least four of these must apply. The disorder can be episodic or persistent. When diagnosis has been made and a person does not meet any of the criteria for 12 months or more, sustained remission is said to apply (American Psychiatric Association 2018).

The prevalence of pathological problem gambling in the Australian population was estimated in 2010 by the government’s Productivity Commission at 0.7% of adults (then 115,000) with a further 1.7% (280,000) experiencing moderate-risk problem gambling (Australian Productivity Commission 2010). However, a 1996 review of global studies on the prevalence of pathological gambling argued that most published estimates greatly over-estimated the prevalence because of failure to distinguish between people ever having experienced problem gambling and those currently experiencing it (Walker and Dickerson 1996).

Rates of recovery, treatment seeking and natural recovery from pathological gambling were estimated from two United States national surveys: the National Epidemiologic Survey on Alcohol and Related Conditions, and the Gambling Impact and Behavior Study (Slutske 2006). Both surveys found that the rates of recovery and treatment seeking were about 40% and 10% respectively, and that most who at any time in their life had experienced pathological gambling and recovered did so without any formal treatment.

An Australian paper drawing on the Australian Twin Register database found that 104 out of 4,764 people had ever experienced problem gambling, and that 82% of these had moved out of their gambling problems without any treatment (92% of men and 57% of women) (Slutske, Blaszczynski et al. 2009). Notwithstanding this, a 2012 review in Australian Family Physician made no mention of natural recovery, recommending that doctors refer patients to community support groups (Rodda, Lubman et al. 2012).

Many who have had personal histories of alcoholism, narcotics dependency and problem gambling have experienced many years of traumatic impact on their lives. They may have experienced devastating financial losses, family and friendship breakdown, job loss, imprisonment and significant health problems. Their problems have often deeply alienated them from family and friends, and they experience social stigma.

Over the last 50 or so years, tobacco smoking has become deeply denormalised (Chapman and Freeman 2008) in many nations as smoking prevalence plummets, and places and occasions where smoking is not permitted become ubiquitous. While smoking might be said to have become increasingly stigmatised, particularly when smokers impose their smoking on others (Colgrove, Bayer et al. 2011), the level of stigmatisation of smoking is incomparably less than the stigma that applies to problem drinking, narcotic dependence and serious problem gambling. So while we have seen that there are commonalities between how most people uncouple from these dependencies and the way that most smokers quit, there are also important differences.

Chief among these is that ex-smokers are typically anything but ashamed of their achievement in quitting. Many are very forthcoming about it and happy to describe their experience. Those who have recovered from serious and chronic drinking problems are often similarly proud of their achievements, but probably many more are reticent about it because of the more enduring and powerful stigma involved, and anxieties that telling people about significant past phases of life where one was a problem drinker might trigger circumspection in others.

As we will see in Chapter 7, smokers who have quit unassisted have many deep insights into why and how they went about it and what they see as key factors explaining their success. Their insights are rarely embraced by those trying to promote quit attempts. This is largely because those with fundamental vested interests in commodifying and professionally mediating smoking cessation are naturally drawn to study smokers who use their products and services, and to both de-emphasise and often denigrate unassisted cessation as failure-ridden folly (see Chapter 5).