Visions for the future: Quitting smoking

In the first of a two-part series, we’ll look at how we can help more people quit smoking. In part two, we’ll look at how to make the most of the UK’s Stop Smoking Services. But first we’ll look at potential future ways to kick the habit.

Quitting smoking can be hard. Nicotine may be legal, but it’s just as addictive as heroin or cocaine. And because quitting is tough there’s help out there that improves your chance of success.

The NHS Stop Smoking Services offers help to smokers to kick their habit, including medication to curb cravings, and behavioural support through one-to-one counselling, group therapy, telephone counselling or online support.

Last year almost 600,000 people in the UK tried to quit through NHS Stop Smoking Services, around half doing so successfully by four weeks.

And evidence shows the NHS service roughly triples your chances of successfully stopping smoking.

But we want to aim higher.

Tobacco causes about a quarter of all cancer deaths. Upping the quit rate, even by a few per cent, could really benefit the nation’s health. If the UK was tobacco-free, we could prevent over 60,000 cases of cancer each year, as we’ve blogged about before.

E-cigarettes are a promising way to help some smokers quit – and we’ve blogged extensively about their challenges and opportunities.

And there are also improvements that could be made to Stop Smoking Services immediately – like more funding – but we will look more closely at that in part two.

But what else is out there? For No Smoking Day we gazed into our crystal balls and took a look at some potential future innovations that might help people quit smoking.

Let’s Get Physical

First, let’s start with managing the physical addiction to nicotine.

Nicotine changes the balance of chemicals in the brain. When it gets into the body, it activates the brain’s reward centre by increasing levels of a chemical called dopamine.

Dopamine is thought to be part of what gives smokers that feeling of pleasure every time they take a drag and plays a key role in making them want to continue.

To help wean smokers off nicotine, the NHS offers nicotine replacement therapy (NRT) in various forms including patches, gum, and inhalers as well as prescription medications.

But what if there was something that made it easier to quit?

Nicotine Vaccine

It sounds far-fetched, but could you programme your body to attack nicotine? Scientists have been working on a nicotine vaccine that aims to do just that.

Back in 2005 a company called Nabi Pharmaceuticals – with support from the U.S. National Institute on Drug Addiction – started developing a vaccine called NicVax.

It was designed to work by stimulating the immune system to recognise nicotine as a foreign invader. The body then reacts by creating antibodies that attack and bind to the nicotine molecules, lowering its levels in the blood.

By reducing nicotine levels in the blood stream, the vaccine would stop nicotine from entering into the brain’s reward pathway, and – in theory – prevent smokers from getting that dopamine boost when they took a drag.

Early trials of NicVax were promising, but the Phase III trial results weren’t great.  The vaccine only produced nicotine antibodies for a third of participants and, overall NicVax was no better than the placebo in helping people quit.

But if at first you don’t succeed, try, try again. Researchers at The Scripps Research Institute in California gave it another go and designed a new vaccine that may provoke a better immune response.

Dr Kim Janda, a researcher at The Scripps who worked on the new vaccine, explains that nicotine has two forms that are like mirror images of each other: one is the “right-hand” version and one is the “left-hand” version.

The vast majority of the nicotine found in tobacco is the left-hand version and the problem with the earlier vaccine was that it targeted the right-hand version of nicotine.

In the new study, the researchers created three different vaccines: one that focused only on the left-hand version of nicotine, one that focused on the right-hand version and one that was a 50-50 mixture of both.

They tested the different vaccines in rats and found that the left-handed vaccine created four times more nicotine antibodies than right-handed version.

Dr Jonathan Lockner, lead author of the study, suggested that “future vaccines should target that left-handed version”.

But it will be a while before there’s conclusive proof that any nicotine vaccine will work in people.

Also, there’s a problem with this strategy: while it might reduce nicotine’s pleasurable effects it’s unlikely a vaccine would remove another key hurdle: withdrawal symptoms.

Targeted Treatment

Nicotine withdrawal causes physical symptoms, such as headaches, nausea, irritability and anxiety, to name a few, making it not so fun to quit.

Existing treatments like NRT or varenicline aim to target these, as well as gradually weaning smokers off nicotine.

Trials exploring how NRT improves the chance of quitting, compared with going it alone, have shown improvements of 50-70 per cent. But, a study following people using NRT bought over-the-counter – rather than as part of a trial, or alongside counselling or other support to stop – has been less successful.

But there are other drugs that can help, like varenicline (Champix) and bupropion. Research has suggested higher success rates with these treatments; particularly varenicline. These treatments are available to over 18s on prescription to help curb cravings.

But we are all unique snowflakes, so what’s the best treatment for each person? The short answer is, ‘we don’t know’. But research is beginning to suggest that in future there may be ways to tailor the right intervention to the right people.

For example, a recent study published in The Lancet Respiratory Medicine found the benefit of varenicline over NRT was stronger in people biologically predisposed to break down nicotine more quickly than those who break it down slowly.

Although this isn’t conclusive, it suggests that people trying to quit in the future may benefit from a more tailored drug treatment plan to target individual physical cravings – possibly even through a DNA test.

But, it’s not all about the physical symptoms.

Tobacco addiction has three parts: physical – which we’ve covered above, but also psychological and social – which we’ll look at now.

Research has shown that addressing the psychological and social aspects of addiction is critical in preventing people from relapsing.

The behavioural support offered by stop smoking services can be a combination of health education, motivational interviewing and, occasionally, more intensive psychotherapy such as cognitive behavioural therapy, which focuses on changing thoughts and actions about smoking.

And the evidence shows that behavioural support can make a big difference in successfully giving up.

But what about the social aspect of addiction?

Virtual Reality

When Pavlov’s dog heard a bell ring it would salivate because it thought it was going to get food. Similarly, every time you smoke, you subconsciously train your brain to crave cigarettes during certain situations or when you encounter particular emotional states, like stress.

To help people cope with situations that trigger cravings, traditionally, therapists role-play a friend or someone offering them a cigarette, and then teach them strategies to avoid falling back into old habits.

But, as you can imagine this isn’t very realistic and doesn’t work all that well.

Recent research has showed promise with virtual reality therapy (VRT) – a method of psychotherapy that uses virtual reality technology to treat patients.

By creating hyper-realistic virtual worlds, that even include smells, scientists can recreate situations that trigger cravings.

https://www.youtube.com/watch?v=OTuBT0Dsvvo

The goal is to get the patient craving the virtual drug, and then help them cope with those feelings so they can deal with the cravings better in ‘real’ life.

A small feasibility study conducted by Patrick Bordnick, from the Graduate College of Social Work at University of Houston, showed that smokers who received VRT had significantly lower nicotine cravings and smoking rates.

The study involved 86 nicotine-dependant smokers who were given either VRT combined with NRT, or just NRT. At the end of the 10-week trial, those in the VRT+NRT group seemed to have much lower nicotine cravings, and appeared more confident in resisting temptation.

But, this study doesn’t compare apples with apples. First, it isn’t clear how well the characteristics of the people in the two groups were matched. And those in the VRT group spent more time in treatment, so the level of intensity of the treatment may have had more impact than the VRT itself.

Another small pilot study of VRT, conducted by Canadian researchers, found that when smokers were placed in a virtual reality game where they had to seek out and crush cigarettes, their cravings went down. The study included 91 smokers who were randomly placed into two groups: crush cigarettes or collect balls. Results showed that 15 per cent of those in the “crush cigarettes” group had abstained from smoking by the end of the 12-week trial, compared with only two per cent from the ball-collection group.

So there are tentative signs that using VRT to help smokers cope with the social part of their addiction could be useful.

But the possibility of using virtual reality is a way off: research on virtual reality therapy is in its infancy and needs more rigorous evidence to support it, along with it not yet being widely available. Also any adverse effects need to be explored.

Looking ahead

But the future looks promising.

This blog hasn’t discussed e-cigarettes, which have huge promise, although we need to know how to use them best, how safe they are long-term, and whether they have unintended consequences.

There are other initiatives in the pipeline too:  for example, using financial incentives like gift vouchers to help certain groups of people, like pregnant women, to quit.

But we hope that more resources and better  research will improve  stop smoking options in the UK, and success rates for quitting will increase.

After all, an estimated two thirds of smokers say they want to quit – we need to do everything we can to help them.

–Misha Gajewski

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Image via Little Visuals licensed under CCo 1.0 Universal (CCo 1.0)