Addicted to Nicotine
A National Research Forum

Section VI: Treatment of Nicotine Dependence
John Hughes, M.D., Chair

INTERVENTION FOR TREATMENT-RESISTANT SMOKERS

Karl Olov Fagerstrom, Ph.D.
Fagerstrom Consulting

Introduction

One way the term "treatment resistance" can be meaningfully applied to tobacco use is when the individual is not aware of the health effects of smoking as a problem. In this scenario, there is little likelihood that any actions will be taken, particularly when the problematic behavior is reinforced by a psychoactive drug. Fifty years ago this type of treatment resistance was probably stronger than today. It therefore seems that information about the negative effects of smoking is needed, first and foremost, as a prerequisite for further actions to be effective.

Tobacco smoking contributes to morbidity and mortality; it is also a dependence disorder by itself, and there can be resistance to giving up a dependence. Resistance can differ in these two different states (e.g., a smoker might want to reduce the risk of mortality but be reluctant to give up nicotine's effects). Such a smoker might want to change to safer tobacco products or to pure nicotine products if the correct information about these alternatives were available.

Many smokers are resistant to treatment even though they are very well informed. Some smokers have tried to give up several times but failed because the abstinence symptoms were too strong. For such smokers, new alternatives to abrupt quitting are very much needed. It may be that after some time they stop listening to quitting advice because of the discomfort quitting can cause. If they believe quitting is not possible, they also may not seek help. One option is for a more intensive quitting treatment. Another option may be a reduction in smoking. The latter will be the focus of this presentation.

What We Know

Nicotine has traditionally been seen as harmful and addictive. It is absolutely clear that nicotine, delivered by cigarettes, can cause dependence. However, nicotine from cigarettes does not contribute much to the total mortality and morbidity of smoking. With pure nicotine products (e.g., gum, patch, etc.), it seems that the harm in terms of physical disease is very minimal, with the possible exception of pregnancy (nicotine can have harmful effects on the fetus).

Yet ironically, nicotine presents an opportunity in combating smoking-related morbidity and mortality. There is a dose-response relationship in most smoking-related illnesses (i.e., the more smoking, the bigger the harm). Therefore, less smoking would result in less harm. Evidence is growing that shows many smokers who find it difficult to give up smoking nevertheless would like to reduce the harm associated with smoking. It is in such situations that nicotine from alternative sources could (a) interest the resistant smoker to take some action and (b) reduce the risk of smoking.

Initial research has provided some encouraging results when quitting-resistant smokers are given an opportunity to reduce cigarette smoking. Not only does the toxic intake from smoking decrease, but also a more favorable risk factor profile for the airways and the cardiovascular system occurs. A reduction in smoking has generally not worked well toward abstinence, and concerns have been raised that reduction undermines a smoker's motivation to give up entirely. That worry has not come true in the initial research. On the contrary, having more control over smoking may increase a smoker's motivation to quit, even among those with little or no interest in doing so.

In summary, the following facts are known:

• Most (though not all) smokers are aware of the medical risks and addiction involved in smoking, yet most have not quit.

• The harm from smoking is related to exposure.

• Although the public believes nicotine to be among the most dangerous of tobacco toxins, in reality, the toxic harm associated with nicotine itself is relatively minimal.

What We Need To Know More About

An important topic to learn more about, in well-controlled trials, is whether a reduction in smoking increases or decreases the number of quit attempts or successful quitting. Even if a smoker's motivation to quit or actual quitting does not change, reduced smoking might still be preferable. For while reduction in smoking does not reduce dependence, it would reduce harm.

Evidence so far suggests that nicotine replacement therapy could be used as an aid in smoking reduction. However, placebo-controlled trials are needed to support this hypothesis.

The best candidates for a reduced-smoking message must also to be discussed (e.g., those who are motivated to quit, or intend to give up soon, probably should not be targeted). It may be safer to address this nonimmediate cessation message to smokers who do not have a current motivation to give up or have been discouraged to give up because of difficulties encountered. We need to find out which category of smokers is interested in reducing smoking. Is it those who smoke little and have a low dependence? Or is it the heavily dependent smokers who are at high risk for diseases? And what sort of comparative risks do each of these face?

Two final questions remain: Does a 50-percent reduction in exposure to tobacco toxins reduce risk by 50 percent? And, is a 50-percent decrease in exposure equally important regardless of baseline smoking (e.g., 40 to 20 versus 10 to 5 cigarettes per day)?

In conclusion, we need to know more about:

• Whether reduced smoking affects the resistance and motivation to give up.

• Whether nicotine replacement is effective in aiding reduced smoking.

• Who are the best candidates for a reduced-smoking approach (e.g., Is reduced smoking more beneficial for heavy smokers?).

Recommended Reading

Jiménez-Ruiz, C.; Kunze, M.; and Fagerstrom, K.O. Nicotine replacement: A new approach to reduce tobacco-related harm. Eur Respir J 11:473-479, 1998.

Ramstrom, L.; Uranga, R.; and Hendrie, A., eds. Social and Economic Aspects of Reduction of Tobacco Smoking by Use of Alternative Nicotine Delivery Systems. A Summary of a Round Table Organized by the U.N. Focal Point of Tobacco or Health, September 22-24, 1997. Chester, UK: AIDIS International Limited, 1998.

Warner, K.E.; Slade, J.; and Sweanor, D.T. The emerging market for long-term nicotine maintenance. JAMA 287:1087-1092, 1997.