Smoking Cessation, Part I: Challenges with current products

Introduction:

It’s clear that smoking is bad for your health, and plenty of research supports this claim.

In a sign of better education and health awareness, the number of cigarette smokers have been dropping steadily over time from ~40% in 1965 to ~12% in 2023 of the US population.

In an ideal world however, there would be a grand total of 0 people smoking cigarettes, and following the linear decreasing trend above will still take until 2046 for all cigarette smoking to stop.

Clearly we still have a long way to until little to none of the population smokes, and thus there is still a strong need for effective smoking cessation products.

It’s not just the non-smokers that like to see cigarettes gone; smokers want to quit as well, as 55% of all smokers have attempted to quit smoking. Quitting isn’t a one-time effort either; about 75% of those who try to quit do so through multiple attempts and methods, highlighting not only the challenges and persistence required in cessation efforts, but also the willingness of smokers to try and quit.

But why do current options seem so ineffective? In part I of this series on smoking cessation, we will start by looking at the quitting options available to smokers, understand how it’s supposed to work, and why the supposed success stories seem to be the exception more than the norm:

Self-directed Quitting:

Cold Turkey:

What it looks like when it works:

A family friend of my parents, a 30 year smoker, was driving with 3 other friends on the highway one day, and as they were lighting a cigarette up, one of them remarked, “why are we doing such harmful things to ourselves?”, and four of them collectively decided to throw all the cigarette packs they had on them out the car window (I assume there is a bit of embellishment on his part; that would have been highly dangerous).

Fighting through sweaty, agitated daytimes and sleepless, nightmare-filed nights where he dreamed constantly of smoking, our family friend finally kicked the habit for good after a few months. While we eventually fell out of touch with him, I assume he’s living a healthier, happier life without cigarettes.

Why is this the exception rather than the norm:

Quitting cold turkey involves stopping all nicotine use abruptly. While this method is simple and free, it has a success rate of only about 5%. There are two primary reasons why:

1. Nicotine dependence: Nicotine is highly addictive, and the body becomes dependent on it. When nicotine intake stops abruptly, the body goes into withdrawal. Nicotine affects neurotransmitters in the brain, especially dopamine, which is associated with pleasure and reward. Without nicotine, the brain struggles to produce these chemicals at the same levels, leading to withdrawal symptoms such as headaches, fatigue, and irritability.

2. Lack of behavioral support for psychological dependence: Smoking often becomes a coping mechanism for stress, anxiety, or boredom. Without nicotine, these feelings can intensify, causing psychological withdrawal symptoms. There are also daily routines and activities often involve smoking, such as having a cigarette with coffee or after meals. Removing these habitual triggers can lead to cravings and withdrawal symptoms.

Most people first attempt cold turkey alone, relying solely on willpower, as my family friend did. But without pairing with some form of pharmacological intervention to lessen the withdrawal symptoms, and behavioral support to keep the patient from slipping back into their old habits, quit attempts are likely to fail in the long run.

Over-the-Counter Nicotine Replacement Therapy (NRT):

What it looks like when it works:

If we modify my family friend’s story, here’s what it would look like:

Aware that quitting smoking can have unpleasant withdrawal symptoms, my family friend decided to use over the counter NRTs (nicotine gums, patches, and lozenges) to satisfy his nicotine cravings and reduce the withdrawal symptoms. Over time, our family friend decreased the amount of NRTs he needed a day, and eventually stopped using them altogether to enjoy a nicotine-free life.

Why is this the exception rather than the norm:

Products like nicotine gums, patches, and lozenges are widely available, and work by providing nicotine to the user without having to smoke it from a cigarette. However, they are not without their issues.

1. Slow Nicotine Delivery: Nicotine replacement products like gums and patches deliver nicotine much more slowly compared to smoking. Smoking a cigarette results in a quick spike in nicotine levels in the bloodstream, which provides immediate relief from cravings. In contrast, the slow delivery of nicotine from NRTs means that cravings are not addressed as effectively or promptly. This often leads to continued cravings and potential relapse.

2. Difficult to track/guide usage: The user is supposed to start with a high dosage and gradually reduce it over time. However, this dosage reduction needs to be done correctly. Cutting down too quickly can lead to underdosing, causing intense cravings and a higher risk of smoking relapse. Conversely, staying on NRTs for too long can lead to continued nicotine dependence, and cause side effects like sleep disturbances, headaches, and nausea.

3. Does not address the physical aspects of smoking: Similar to quitting cold turkey, NRTs remove the act of smoking abuptly, which is a significant part of the addiction. The physical habit of smoking, such as hand-to-mouth movements and the sensory experience of inhaling smoke, is not addressed by these products. This can lead to negative withdrawal symptoms and a feeling of something missing, making it harder to stay committed to quitting.

NRTs alone may help make the quitting process less painful, but still require significant input and mental fortitude from the user to overcome the NRT product deficiencies and actively quit smoking. In fact, some studies even show current NRTs are no more effective than quitting on the smoker’s own.

Clinician Guided Quitting:

Prescription NRTs:

What it looks like when it works:

Again modifying the original family friend story:

After trying to quit cold turkey, using over the counter NRTs and failing to effectively quit, our family friend decided that it was better to seek professional help. He went to see his primary care physician, who prescribed him prescription NRTs (Chantix, nasal sprays), and put him on a 12 week treatment with clinical guidance , after which he was gradually weaned off the prescription NRT.

Why is this the exception rather than the norm:

Much like over the counter products, prescription NRTs have some serious downsides:

1. Chantix (Varenicline): Chantix works by binding to nicotine receptors in the brain, reducing the pleasure derived from smoking and alleviating withdrawal symptoms. It has been linked to severe side effects such as mood changes and depression and was recalled in 2021 due to carcinogenic impurities, which have significantly damaged its market trust.

2. Nicotrol: Both the inhaled and nasal spray works by delivering a concentrated dose of nicotine to the nasal passage or back of the throat. However, such high concentration of nicotine in a small area can often cause significant irritation, and the inhaled version has recently been discontinued due to manufacturing difficulties.

While prescription NRTs may be perceived to be more successful than over the counter NRTs due to the additional clinical intervention, studies show that they actually aren’t, and much of the success may come from frequent clinician visits and reminders to stay on track with their quitting program.

Cigarette Alternatives:

What it looks like when it works:

I learned about my family friend’s quit attempt in the ‘90s before cigarette alternatives existed, but I assume his story would have looked something like this:

My family friends started using e-cigarettes as a way to wean themselves off traditional cigarettes. Initially, the e-cigarette helped a lot. The hand-to-mouth action and the inhaling sensation were similar to smoking, which made the transition smoother. They chose e-liquids with lower nicotine concentrations and gradually reduced the nicotine level over time. This approach helped them manage cravings without the harmful effects of smoking.

They found that the e-cigarette was a useful tool, but knew they needed to eventually quit nicotine altogether. To aid this final step, they introduced nicotine pouches into their routine. These pouches provided a discreet and convenient way to get their nicotine fix without smoking or vaping. They were easy to use at work or when out with friends.

Over several months, my family friend slowly decreased the number of pouches used each day. The pouches helped control cravings without the need for smoking or vaping. The absence of smoke and vapor also made it easier to break the psychological addiction to the act of smoking.

Why that is the exception rather than the norm:

Smoking alternatives are billed as “safer alternatives” to cigarettes, rather than a tool to quit smoking altogether. While some people may be able to use it as a way to switch off of cigarettes as a first step, the business model of these companies are clearly to keep users on their product for as long as possible, as opposed to having people quit nicotine use using their products. In addition, these products have serious downsides:

1. E-cigarettes: While popular, e-cigarettes heat nicotine, leading to the inhalation of potentially harmful byproducts within their device. These health concerns have hindered their acceptance as a legitimate cessation tool. Not only that, the heated products itself can cause damage to the lungs.

2. Zyn (Nicotine Pouches): Designed as a smoke-free alternative, Zyn and similar products can cause gum irritation and raise concerns about long-term oral health, including the risk of mouth cancer. They are also not primarily intended for quitting smoking, which limits their effectiveness as cessation aids.

To date, no E-Cigarette products being approved by the FDA as a cessation device, much less a safer alternative to cigarettes.

Conclusion:

While there are many smoking cessation products for smokers interested in smoking to choose from, it’s evident that they all have some serious flaws in either the core mechanism of action, or how the product is delivered and used, contributing to the lack of improvement in successful quit rates. If we are to continue efforts to reduce the number of smokers (which in our opinion should be down to zero), there needs to more effective smoking cessation products on the market that can more effectively shepherd smokers through the physical and mental challenges of quitting.

Curious to know what we think makes a successful smoking cessation product? Tune in next week as we deconstruct what the ideal attributes of such a product should be!

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