Getting smokers to quit with an unlikely drug: Nicotine

Ed Ellerbeck, M.D., M.P.H., co-leader of The University of Kansas Cancer Center's Cancer Control & Population Health Program, and chair of the Department of Preventive Medicine and Public Health at The University of Kansas Medical Center, is studying an alternative method to quitting smoking for people who have chronic obstructive pulmonary disease (COPD) without requiring them to attempt to quit abruptly.

COPD is a mix of chronic bronchitis (which involves a constant cough) and emphysema (which destroys lung tissue). Most people who develop COPD are older with a history of smoking. The Centers for Disease Control estimates that smoking is the cause for as many as nine out of 10 COPD-related deaths, yet 39 percent of people with COPD continue to smoke.

Most people with COPD still continue smoking because it's a habit they simply cannot break, even though they have lung disease and are at a high risk for cancer. Blame it on the nicotine.

"A common misconception is that nicotine causes cancer," said Dr. Ellerbeck. "It does not. Nicotine is terrible because of its addictive properties."

Nicotine stimulates the reward pathways in the brain, which is why most people can't just have one cigarette every once in a while. They're always craving the feeling of satisfaction they get from smoking. Dr. Ellerbeck is studying whether people would quit smoking if they were allowed to keep having nicotine.

He is dividing several hundred smokers with COPD into two groups. One group will partake in 12 weeks of conventional smoking cessation counseling (cold turkey quitting with the help of a drug), along with 10 weeks of nicotine replacement therapy (NRT). The other group will participate in a year of NRT, along with five counseling sessions focused on gradually stopping smoking.

Nicotine replacement therapy includes going on a nicotine patch and supplementing with lozenges and gum. In the second group, the participants are still allowed to smoke, but they can use as much nicotine therapy as they want. Nicotine is not biologically harmful in the way that the carcinogens in cigarettes are, explained Dr. Ellerbeck.

"The part that causes cancer in the cigarette is the combustion byproducts that come off when the cigarette burns," he said.

To see which method is more effective at curbing smoking, people in the study will have their urine tested for NNAL, one of those chemicals that comes from tobacco but not from nicotine. They will also receive breath tests to measure carbon monoxide levels, every three and six months as well as one year.

The hypothesis is that since the second group has access to nicotine whenever they want in the form of patches, gum and lozenges, they will rely on those to satisfy their cravings rather than an actual cigarette.

Program enrollees are very familiar with the struggle to quit. One participant said, "When I quit before, I was so angry and cranky that my friends and family begged me to go out and buy cigarettes. It [quitting] just wasn't worth it."

And the benefits of nicotine replacement therapy were also apparent. "My doctors have been telling me to quit for years, but they don't realize how hard it is," the participant said. "This program is the first time it seems like people understand this and are on my side."

Dr. Ellerbeck is looking to see if people on long-term NRT will have a better quit rate or at least cut back the number of cigarettes they smoke. Even smokers who want to quit usually fail -- only about 4 to 7 percent of cold turkey quitters are successful, according to the American Cancer Society.

A number of previous studies show that it's safe to use NRT and continue to smoke, according to Dr. Ellerbeck, so even if a smoker isn't highly motivated to quit, they will likely at least cut back on the number of cigarettes they're smoking if nicotine replacement is also being introduced.

If participants have quit smoking, but are still using nicotine replacement therapy when the study is over, Dr. Ellerbeck said he would consider that a success. He's also hoping smokers will be more open to this nuanced approach to quitting, rather than someone telling them to immediately throw their cigarettes in the trash and expect them to be successful.

"We sometimes say smoking is a personal choice," said Dr. Ellerbeck. "We blame the victim of smoking and say they make this choice; however, it usually was made when they were a teenager and now their brains have been wired to this addiction. Quitting becomes a very difficult option so we're trying to think of it more as a chronic disease with this research."