Wednesday, February 10, 2010

Research: Nicotine Alone is Not Enough to Treat Smoking Addiction; Behavioral Components Must Also Be Treated

Research Explains Why Electronic Cigarettes May Be So Effective in Promoting Smoking Cessation

According to research published in the 2005 issue of the journal Addiction, nicotine replacement alone is not enough to suppress all the symptoms of smoking abstinence; smoking-related stimuli may also be needed to successfully suppress the complete range of smoking withdrawal symptoms (see: Buchhalter AR, Acosta MC, Evans SE, Breland AB, Eissenberg T. Tobacco abstinence symptom suppression: the role played by the smoking-related stimuli that are delivered by denicotinized cigarettes. Addiction 2005; 100(4):550-559).

In the study, smokers were given either nicotinized cigarettes, de-nicotinized cigarettes, or no cigarettes and were monitored over a five-day period for a range of withdrawal symptoms. The key finding was that even in the absence of nicotine delivery, the smoking-related (behavioral) stimuli associated with the de-nicotinized cigarette were sufficient to suppress a number of the important symptoms of smoking abstinence, such as the urge to smoke.

The article summarizes the results and conclusion as follows: "Smoking-related stimuli are sufficient for suppressing some symptoms of tobacco abstinence over a 5-day period [i.e. Questionnaire of Smoking Urges (QSU) factor 1, 'Desire for sweets', 'Hunger' and 'Urges to smoke'], while in this study a combination of nicotine and smoking-related stimuli suppressed other symptoms (i.e. 'Difficulty concentrating', 'Increased eating', 'Restlessness' and 'Impatient'). These results indicate that, while some tobacco abstinence symptoms may be suppressed with nicotine, suppressing others may also require strategies that address the absence of smoking-related stimuli."

The article describes the implications of this research as follows: "Much research has been based on the assumption that nicotine dependence is responsible for all tobacco abstinence symptoms. The validity of this assumption is challenged by the fact that smoking-related stimuli alone—without nicotine—can suppress tobacco abstinence symptoms, at least for a 24-hour period. To the extent that non-nicotine, smoking-related stimuli alone can suppress tobacco abstinence symptoms indefinitely, the role of nicotine in treating these symptoms is uncertain."

The article notes that for specifically treating the urge to smoke that arises during abstinence from smoking, nicotine replacement therapy may be less effective than behavioral treatment: "When they [smokers trying to quit] complain of urge to smoke or increased hunger, behavioral techniques may be more helpful in symptom suppression than higher NRT doses."

The Rest of the Story

This research may help to explain the observation that electronic cigarettes seem to be effective in helping smokers achieve smoking cessation, even though results of a clinical trial using these products appear to find that at least some of these products may deliver very little nicotine.

The reaction of many anti-smoking advocates and researchers to the news yesterday that electronic cigarettes "don't deliver nicotine" was that these products are therefore not effective in treating smoking addiction and helping smokers quit. However, it may be that these researchers and advocates are overemphasizing the role of nicotine in suppressing the urge to smoke during smoking cessation attempts.

This research demonstrates that behavioral stimuli are not only important in suppressing smoking abstinence symptoms, but that for some symptoms - such as the urge to smoke - smoking-related stimuli may play a critical role. In other words, this research provides a strong theoretical foundation for the use of electronic cigarettes in smoking cessation, because it shows that the behavioral aspects of smoking alone - even in the absence of nicotine - can help to relieve the urge to smoke during smoking cessation.

The overemphasis on nicotine replacement therapy for treatment of "nicotine" dependence is no coincidence. I believe that the strong influence that Big Pharma money has had on the tobacco control movement has contributed to this apparent distortion of the role of nicotine compared to behavioral factors in maintaining smoking addiction. Not only are pharmaceutical companies funding many researchers in the anti-smoking movement, but the major tobacco control conferences - both national and international - are now sponsored by pharmaceutical companies. Moreover, the expert panel which recommended that nicotine replacement therapy be the mainstay of smoking addiction treatment was chaired by an individual who had a severe conflict of interest with Big Pharma, and at least seven of the expert panel members had conflicts of interest related to making money from pharmaceutical companies.

The rest of the story is that there is scientific research documenting that behavioral stimuli play a large role in the smoking addiction process. There is a theoretical rationale for why nicotine replacement alone would not be expected to fully suppress smoking abstinence symptoms. This research explains why electronic cigarettes represent such an important innovation in the treatment of smoking addiction. And the research might explain why electronic cigarettes appear to be so effective in helping smokers quit even though the devices may not actually deliver much nicotine.

(Thanks to Dr. Tom Eissenberg, the senior author of this study, for calling it to my attention.)

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