Various treatments have been tried “on smokers.” The vast majority of these have the stated goal of helping people who intend to “quit smoking.” Another group has the secondary objective of counteracting nicotine withdrawal, both in people who stop smoking completely and in those who reduce their smoking without quitting entirely. The underlying idea is that eliminating the discomfort caused by stopping smoking should make it much easier to remain abstinent.
A minority of studies, however, measure something far more important for “dependent” smokers: interrupting the course of nicotine dependence, in other words, the ability of treatment to bring about a spontaneous reduction or cessation of smoking, as well as the relapse rate.
The first type of study—those focusing on smoking cessation—requires only a few months of follow-up (let us say up to 6 months), whereas the others require at least one year. Sometimes effective treatments are effective both in helping people quit smoking and in preventing relapse. At other times, what helps a person quit has no ability whatsoever to prevent a return to cigarettes.
The general limitation of research is that everyone is eager to see “immediately” whether a method is promising or not. Consequently, a large number of studies are conducted over short periods: 1, 3, or 6 months. This creates many false hopes, or at least conclusions that are of little use to “dependent” smokers, because quitting smoking and preventing relapse are two different objectives: the first does not predict the second.
Indeed, one could say that the first outcome—quitting—is already part of the experience of most people dependent on any substance, legal or illegal. A dependent person has experienced being able to stop. Later, as the dependence progresses, they may stop trying altogether because they have learned that stopping does not guarantee a stable outcome.
At present there are numerous products that are useful for quitting smoking, and it is difficult to classify them according to their mechanism of action. The factors that help people quit are multiple. A substance with antidepressant properties may be useful, as may one that acts more directly against withdrawal, as well as one that counteracts the effects of nicotine and thereby promotes a sense of “boredom” or lack of interest in smoking.
This entire therapeutic arsenal should be understood as short-term treatment, unless the person has psychiatric disorders that are worth continuing to treat, perhaps diagnosed precisely when they attempt to quit smoking.
For many people suffering from depression or anxiety, quitting smoking is traumatic and therefore difficult because “it is never the right time.” With every attempt, symptoms of anxiety and depression may temporarily worsen, and this can become a major obstacle to completing the withdrawal process.
Many people with an active and dynamic temperament also have difficulty tolerating the “depressive” phase that accompanies smoking cessation, characterized by sleepiness, lack of concentration, and slowness in carrying out tasks. Even when this phase resolves, it may do so slowly in a way that is poorly compatible with practical demands, or it may be interpreted pessimistically, as though the person were descending into an abyss rather than simply going through a temporary withdrawal phase.
There are then treatments aimed at recovering control, whose objective is to reduce or stop smoking—even if not abruptly—and to prevent relapse.
At present, it is possible to say that if a treatment has achieved the first objective (reducing or stopping smoking) and the person has a diagnosis of nicotine dependence, discontinuation of treatment is associated with a risk of relapse that increases over time. This is a characteristic feature of dependence.
Non-dependent smokers tend to have their risk of relapse concentrated in the early phase: the longer they remain without smoking, the lower their risk becomes. By contrast, a “dependent” smoker who has stopped and is receiving no treatment tends to relapse over the course of time. Thus, paradoxically, someone who has not relapsed immediately may have a high probability of relapsing later.
Naturally, we are talking about “dependent” smokers—that is, people with a specific diagnosis. This does not simply mean being a “habitual smoker,” a “hardened smoker,” or a “heavy smoker.” These terms often refer to the quantity or emotional pattern of smoking, but they do not specify the person’s ability to control smoking or their intention to stop. These are the fundamental diagnostic elements that distinguish dependent smokers from non-dependent smokers.
It is important for the patient to understand that a diagnosis of dependence essentially means a prediction of a relapsing course in the absence of treatment.
The treatments that have been most extensively studied are bupropion, varenicline, and nicotine itself.
Among smokers who do not receive long-term treatment, the probability of still being “free” from smoking at one year is, in the most favorable estimates, about 15%. This refers to smokers who have nevertheless undergone some form of cessation treatment lasting several weeks, typically around three months.
Having undergone a short course of treatment with bupropion or varenicline increases the probability of remaining abstinent after one year only slightly. It can therefore be said that these treatments work when they are continued—that is, when the person is still taking the medication consistently at the effective dose one year later.
In this respect, the most effective treatment appears to be varenicline, with the probability of being smoke-free at one year approaching one in three. This figure does not simply include people who “did not relapse” after “quitting,” but also those who managed to quit gradually and then maintained the result.
Differences between individuals can also be seen within these studies. Those who are able to stop easily from the outset are also those who are less likely to relapse at one year, whether or not they receive treatment.
The fact that some studies include “smokers” who are not all “dependent” makes the results somewhat confusing, precisely because a typically relapsing disorder—nicotine dependence—is being mixed together with a non-pathological habit—habitual smoking without dependence.
According to the model already useful in other addictions, a nicotine-acting substance delivered without smoke immediately eliminates the problem of toxicity that is not related to nicotine itself but to its vehicle, namely smoke.
Furthermore, the idea that a constant stimulus without “peaks,” and therefore without a pleasurable nicotine effect, might suppress the desire to consume nicotine corresponds to a model already used in the treatment of other addictions: the model of agonist therapies.
Varenicline is precisely a nicotine receptor agonist, meaning that it acts on the same receptors as nicotine. Slow-release nicotine formulations could theoretically produce a corresponding effect, although they have been studied more extensively for withdrawal than as a long-term treatment for craving.
Bupropion, on the other hand, acts on certain general mediators of mood and alertness, particularly dopamine and noradrenaline, while also interfering with the action of externally administered nicotine.
In theory, therefore, it should replace the “beneficial” functions of nicotine while simultaneously preventing nicotine itself from producing them.
This mechanism may work well in some non-dependent smokers, particularly in helping them quit. In dependent smokers, however, it appears to have limited impact. The one-year results are not particularly encouraging: a minority of people benefit from long-term bupropion treatment, but the proportion is roughly one in ten. In some one-year studies, treatment was no different from placebo.
The treatments may have side effects, but overall they have proved to be safe.
Conclusion
In treating nicotine dependence, it is essential to establish:
a) The diagnosis: nicotine dependence or not?
b) The priority of the objectives for general health: for some people, immediate smoking cessation may be necessary to prevent further pulmonary or cardiovascular deterioration, particularly when acute events such as myocardial infarction, pneumonia, respiratory failure, stroke, thrombosis, and so on have already occurred.
c) The long-term objective and the best treatment for achieving it: particularly in “dependent” smokers.
A partial result—for example, a 50% reduction in smoking—should nevertheless be regarded as a partial success, not dismissed.
People who have little ability to stop immediately should still receive treatment if they express a desire to free themselves from smoking.
“Motivation” to quit should not be confused with the capacity to quit. People dependent on nicotine typically combine variable motivation—which tends to decline over time as failures accumulate—with absent control capacity, by definition of their dependence.
Initial support using different means, including medication and psychotherapy, is generally important, but it should not be overestimated or used only in the short term, simply to “quit.”
The fundamental point is to match the diagnosis (dependence or no dependence) with the strategy (short-term or long-term) and with the gradual nature of the results, which does not compromise the possibility of achieving better outcomes over time.
In other words: someone who quits immediately can still relapse a few months later, while someone who does not quit immediately may quit later and remain abstinent.