When at first you don’t succeed: Tobacco researchers to test if switching medications helps people to quit smoking after an unsuccessful first attempt

June 27, 2023
image of two tobacco researchers in hallway
When people struggle to quit smoking using medication, what's the next step? Keep trying or try something else? Drs. Matthew Carpenter and Tracy Smith plan to answer those questions. Photo by Clif Rhodes

The most common outcome of trying to quit smoking is failure – going back to cigarettes. Smoking cessation counselors and researchers know this. The nicotine in cigarettes makes them extremely addictive, so counselors encourage people to keep making more attempts if at first they are not successful. With each new quit attempt, they will hopefully gain better tools to help them to succeed.

“Smoking is a chronic relapsing condition, and we've got to treat it as such,” said tobacco researcher Matthew Carpenter, Ph.D., co-leader of the Cancer Control Research Program at MUSC Hollings Cancer Center. “We know that the most common response to even our best treatments is failure. That's unfortunate, but it's true. So what do we do? That’s the question.”

Doctors who treat other types of chronic conditions often have the benefit of guidelines that point them to next steps if the first treatment fails, said Hollings tobacco researcher Tracy Smith, Ph.D. But such guidelines don’t exist for smoking cessation treatment.

Carpenter and Smith want to provide such guidance.

Together, they received a $3 million grant from the National Cancer Institute to conduct a randomized trial to test whether people are more likely to succeed in quitting smoking if they stick with the medication that they’re first prescribed or if they change medication after a relapse.

And for those who continue to struggle with quitting, they’ll test whether switching to e-cigarettes, which are less harmful, helps them to completely quit traditional combustible cigarettes.

Surveys of people who’ve tried to quit smoking have shown that people who switched medications reported that they were more likely to quit, Smith said.

“This will test that idea in a randomized trial where we really can look at it systematically,” she said.

The Hollings researchers are working with a collaborator at the University of Alabama, Karen Cropsey, Psy.D., to recruit people from across South Carolina and Alabama who smoke and are willing to try to quit.

The Food and Drug Administration has approved seven pharmacotherapy products for quitting smoking. This study will work with the two that have the best track records.

Half of the people in the study will get combination nicotine replacement therapy, which includes nicotine lozenges and patches, and the other half will get varenicline, a medication better known by the brand name Chantix.

Instructions for using these products usually say to use them for 12 weeks. But in this study, if people haven’t succeeded in quitting by four weeks, they’ll be instructed either to switch medications or to keep using the same medication.

The test isn’t whether one medication is better than the other. Instead, the test is whether people are more likely to quit if they change medications if the first one isn’t working, regardless of which one they start with.

If, after another four weeks, people still haven’t been able to quit, they’ll be instructed to either continue with the assigned medication or to switch to e-cigarettes.

Researchers know that e-cigarettes are not completely safe, but they are safer than regular cigarettes. E-cigarettes definitely shouldn’t be used by young people or people who don’t currently smoke. But some think there might be a place for e-cigarettes as an alternative to cigarettes, which can cause a dozen cancers as well as heart disease, diabetes and strokes.

“We are not saying that harm-reduction products, like an e-cigarette, are best for everybody, but we are saying that it might be an option for some people who can't achieve success elsewhere,” Carpenter explained.

Smith anticipates the study could help smoking cessation counselors to help their patients.

“Hopefully, it'll provide guidance to clinicians about how to handle it when their patients relapse, which is the most common outcome,” she said.