Smoking Reduction with Oral Nicotine Inhalers
Abstract & Commentary
Synopsis: This current report found that there was sustained reduction in smoking over 24 months in patients who used nicotine inhalers and that smoking reduction with or without nicotine replacement might be the first step in smoking cessation in people not willing to stop abruptly.
Source: Bolliger CT, et al. BMJ 2000;321:329-333.
Cigarette smoking is associated with detrimental health consequences and the best way to prevent these adverse health effects is to quit smoking. Nicotine in tobacco smoke is the component that causes dependency. By including nicotine replacement therapy in smoking cessation treatments, success rates have been improved.1,2 Chewing gum, transdermal patches, and nasal sprays have been used to supply nicotine to those attempting to stop smoking. However, not all smokers are able to use these products because of the adverse effects. Oral nicotine inhalers have been tried to help smoking cessation with good results.3,4
Bolliger and associates performed a double-blind, randomized, placebo-controlled trial in two university hospital pulmonary clinics in Switzerland. Four hundred healthy smokers who were not willing or were unable to quit smoking, but were interested in reducing their smoking, were randomized to receive oral nicotine inhaler or placebo. After initial assessment and screening, participants were re-assessed after one, two, three and six weeks and at three, four, six, 12, 18, and 24 months. There was a decrease in the number of inhalers used in the active treatment group. Participants in the active treatment group used an average of 4.5 cartridges a day after two weeks whereas participants in the placebo group used 4.9 cartridges a day after two weeks. The cartridge use decreased to 2.6 a day at 18 months in the active treatment group and to 3.9 a day in the placebo group. The reduction in smoking was also higher in the active treatment group, but the difference was significant only at four months whereas the reduction in smoking was 41.5% in the active treatment group and 22% in the placebo group (P < 0.001), with only a trend towards significance at 12 months where the reduction in smoking was 29.5% in the active treatment group and 21.5% in the placebo group (P = 0.085), and at 24 months where the reduction in the treatment group was 27.5% and in the placebo group was 23% (P = 0.357). The smoking cessation rates also increased over time and 38 participants (10%) were not smoking after two years. No serious adverse effect was observed. Two patients reported local symptoms of throat irritation and cough in the active treatment group.
Comment by David Ost, MD & Aamir Awan, MD
Nicotine replacement therapy is an established pharmacologic aid to help smokers quit smoking. Previous trials on smoking cessation have shown that successful abstinence is more likely in smokers with low to moderate nicotine dependance while heavily dependent smokers have higher relapse rates.5 The effect of smoking reduction on smoking cessation has not been studied. In the current study, participants were adult smokers who had failed at least one previous attempt to stop smoking within the past 12 months. Smokers randomized to oral nicotine inhalers during the first four months of trial reduced their cigarette consumption compared with smokers given the placebo inhalers and at the end of the study, it was found that 38 (10%) were not smoking at all. Although this was a small number, this reduction in smoking might be the first step to eventual smoking cessation. Although the overall success rate was small, the active treatment with nicotine inhaler was more effective in obtaining this reduction than the placebo over the two-year period. The combination of oral nicotine inhaler and concomitant smoking was also well tolerated. On analyzing the data, it is evident that even though the number of cigarettes smoked decreased in the active treatment group, there was no corresponding decrease in exhaled carbon monoxide concentration. This may be explained by the fact that the smokers compensated for their decrease in smoking by more frequent puffing or deeper inhalation of the remaining cigarettes. Several important questions, however, are not answered by this trial. It remains unclear whether short or medium term reduction in the number of cigarettes smoked increased the likelihood of long-term cessation. In addition, would "compensatory smoking" offset the expected benefits of smoking reduction in terms of lung cancer risk? What this study adds is that smokers who are unable to quit smoking abruptly can safely use oral nicotine inhalers to reduce the number of cigarettes smoked and, hopefully, as a first step that will lead to eventual smoking cessation.
References
1. Lam W, et al. Lancet 1987;2:27-30.
2. Tang JL, et al. BMJ 1994;308:21-26.
3. Hjalmarson A, et al. Arch Intern Med 1997;157: 1721-1728.
4. Tonnesen P, et al. JAMA 1993;269:1268-1271.
5. Paoletti P, et al. Eur Respir J 1996;9:643-651.
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